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Professor of

A. M.. M. D., Ph. D.

Nervous and Mental Diseases, Jefferson Medical

Philadelphia; Consulting Neurologist to the Philadelphia General Hospital;

Ex-President of the American Neurological Association, of the Philadelphia
Neurological Society, and of the Philadelphia Psychiatric Society; Foreign



of the Neurological Society of Paris,

of the



and Neurological Society

of Vienna;



Medical Society of Budapest,

etc., etc.






SAUNDERS COMPANY PHILADELPHIA . Saunders Company. Reprinted February. by W. 1914. 1917. B.7 Copyright. and recopyrighted November. reprinted. 191 Copyright. Revised. 1913. B. Saunders Company PRINTED IN AMERICA PRESS OF B. by W.

the mental symptoms are in relation with gross visceral or bodily disease. that when viewed from the standpoint of it is internal medicine brought into close and intimate rela- tions with the latter. it Such intoxications may from within the organism. in metabolism. the more we become 9 . with peculiarities of structure in and mental organization often hereditary. the toxic each of these of added and largely unsolved problems Finally. arise from withthe latter out may be. i. or. and with which. In short.y~v rf""* CD .PREFACE TO THE SECOND EDITION The tion of generous reception accorded the first edition of this manual justifies the inference that a purely cUnical presentamental disease fulfils a distinct want. This becomes especially evident when cases of mental disease have their origin we realize that many in infections and intoxications. the more we study insanity. and there are.«^j . difficult and abstruse. again. The practising physician has too often looked upon insanity as a subject unattractive and obscure. given instances. The truth is. however. Among are toxic states due to abnormalities of the various glands of internal secretion or of other structures. T. the physician has to do with aberrancies and arrests of development. again. while others present problems which are essentially those of disorders of metabolism. its because of the speculative and metaphysical character of theories and explanations. . of the latter Many have to do with profound nutritional disturbances in defensive reactions of the which have their origin to organism intoxications. In other cases of mental disease.. he has no immediate concern.

and in the case of dementia prsecox the important interesting results of Fauser of the affection and others on the genesis in the and pathology have been incorporated. . F. and. The volume. This edition. of view. is based upon the annual course at the Jefferson Medical practical point of lectures delivered by the author College. November. the family physician. 1917. and de- scriptions the author has endeavored to present the subject in a simple and yet thorough manner. D. ter on the psychologic interpretation of the The chap- symptoms has been enlarged and sections in part rewritten. first as a whole. and when to com- mit and when not to commit a patient to an asylum. to keep the volume within the limits of a convenient manual. like the first. sufficiently who sees the patient first. thoroughly revised. as in the instances of dementia prsecox and of paresis. Walnut Pa. and has been prepared from a purely In the classification. at the same time. In the present edition the various sections have been ex- panded so as to include.10 PREFACE convinced of the importance of bringing the subject into the closest possible relations with internal medicine. clinical and practical features. the more recent views in regard to pathology and treatment. and he should be informed to be able to recognize mental diseases in their early stages. general arrangement. 1719 X. how the pa- tient should be treated in his own home or elsewhere outside of an institution should this be practicable. as in the emphasis has been laid upon the purely St. has been edition. It is the general practitioner. Phila... and. as have also various on treatment. He should know what to do under given conditions. case of paresis the advance in pathology and the moot ques- tion of treatment have received full consideration.

who sees the pa- and he should be sufficiently informed to be able to recognize mental diseases in their early stages. this book. alike interesting and fascinating. care. Emphasis has been upon the upon prognosis. though . that the insane man is a sick man and of is requires a sick man's need. when to commit and commit a patient to an asylum. however. and upon treatment. from a it may seem an act of temer- ity to present the subject clinical point of view. has been prepared from a purely practical point of view. namely. and. presented.PREFACE Realizing the urgent needs of the medical student is and of the practising physician. the family physician. to keep the volume within the laid limits of a convenient clinical pictures manual. this seems a pressing interpretation The psychologic the symptoms 11 of insanity. In the classification. at the same time. and how the patient or elsewhere outside of an should be treated in his institution own home when this is practicable. presented. general arrangement and descriptions. To the author. In view of the recrudescence within recent years of speculative and metaphysical psychiatry. tient first. which based upon the annual at the Jefferson course of lectures delivered by the author Medical College. and to restate the fact which it took our ancestors so long to acquire. He should know what when not to to do under given conditions. the author has endeavored to present the subject in a simple and yet thorough manner. It is the general practitioner.

Pa. in PREFACE a special part of this volume.. Phila.12 briefly. of public hygiene and prevention. that of internal medicine and that of psy- chologic interpretation. D.. F. X. . To the practising physician. that of internal medicine will ever prove the most important. Our knowledge parallel mental diseases will doubtless advance in two directions: namely. to the needs of state medicine. 1719 Walnut St. and the author trusts that this presentation will prove to be lucid and also adequate to the needs of the student of and practitioner.

Manic-depressive Insanity) (Melan62 Melancholia Melancholia with Agitation Hypomelancholia Melancholia without Delusions Melancholia with Stupor 64 74 76 78 79 81 Mania Hypomania Circular Insanity 93 99 101 The Prognosis of Manic-depressive Insanity in General CHAPTER V Group III— The Heboid-paranoid Affections (Dementia Precox. Mania. Stupor 34 35 39 45 49 56 56 60 Simple Febrile Delirium Specific Febrile Delirium Afebrile Delirium Confusion Passive Confusion Stupor Incomplete Stupor CHAPTER Group IV II Melancholia. Dementia Prajcox Distinguishing Features of the Simple or Hebephrenic 108 113 Form 125 126 127 Distinguishing Features of the Catatonic Distinguishing Features of the Paranoid Form Form 13 .— — CONTENTS PART Introduction. Paranoia) Insanity of Adolescence. I CHAPTER Definitions I PAGE 17 CHAPTER Classification II 26 CHAPTER Group I III Delirium. Confusion. Circular Insanity cholia-mania.

— — 14 CONTENTS PAGE Paranoia Paranoia Hallucinatoria Hypochondriacal Form Self-accusatory Form Mystic Form Paranoia Simplex 138 143 152 152 154 159 CHAPTER Group IV asthenia) VI 175 The Neurasthenic-neuropathic Disorders (Psych- CHAPTER Group V VII 202 The Dementias PART II CHAPTER Affections I The Clinical Forms of Mental Disease Related to the Somatic The Infections Syphilis Tuberculosis Malaria Pellagra 206 207 207 208 209 210 211 Rheumatic Fever The Intoxications Alcoholism and the Alcoholic Insanities Chronic Alcoholism Alcoholic Delirium (Delirium Tremens) Alcoholic Confusion (Alcoholic Confusional Insanity) Alcoholic Paranoia Alcoholic Dementia Plumbism and the Insanities Due Morphinism to 212 212 214 216 218 220 223 224 227 Lead Cocainism Intoxications by Chloral and Other Drugs Disorders of Metabolism Diabetes Gout Adiposis The Visceral Diseases Diseases of the Ductless Glands 233 236 237 238 240 240 241 243 .

. 352 352 Borderland Manic and Paranoid States (The Mattoids) States of High-grade Deficiency. Moral Deficiency. Criminality (The Morons) 354 Sexual Abnormalities 358 Hypochondria 363 CHAPTER Insanity by Contagion IV 377 PART III I CHAPTER The Psychologic Interpretation of the Symptoms 383 .CONTENTS Diseases of the Nervous System 15 -PAGE Functional Nervous Diseases Epilepsy Hysteria Chorea Paralysis Agitans Organic Nervous Diseases Paresis Cerebral Syphilis Multiple Cerebrospinal Sclerosis Arteriosclerosis Hemorrhage. Parturition.. and Thrombosis Brain Tumor and Brain Abscess Tabes 247 247 247 254 265 266 266 266 310 312 312 314 315 31S 32i Trauma Pregnancy. Embolism. the Puerperium. Lactation 324 CHAPTER Mental Diseases as Related to II Age Insanity in Childhood Idiocy and Imbecility Morphologic Idiocies Pathologic Idiocies Cretinism Amavu-otic Family Idiocy Adolescence Early Adult Age Mature Adult Age Middle Age Old Age 330 330 333 334 335 336 338 343 343 344 344 345 III CHAPTER Mental Diseases not Ordinarily Included Under Insanity.

16 CONTENTS PART IV CHAPTER Treatment Prevention I 4J2 412 417 445 Extramural Treatment Intramural Treatment. Index 459 .

s persons possessed of evil spirits. a great retrogression took place. In the rise of the Greek. scientific ex- superstition gradually lost ground and various planations were adopted. Long unrecognized as deaUng with diseased states. has always been somewhat pecuhar. However. the Alexandrian. as the victims of demoniac possession. who were ill.A CLINICAL OF MANUAL MENTAL DISEASES PART 1 CHAPTER INTRODUCTION. These crude and fearsome explanations were singularly like those of the barbarous peoples of our own day. and they were frequently treated by drugs. exercise. as the inspired instruments of the Deity. —looked upon the insane a. more rarely. beginning with about the second or third centuries of the Christian era. or. both as regards the the profession of medicine. and the Roman civilizations. the early Greeks —the Egyptians. 2 Theories of 17 . and up to quite recent times it was the subject of religious and superstitious the He- interpretation. All ancient peoples brews. The insane were looked upon as persons baths. and other hygienic measures. it was looked upon as something apart from medicine. The I DEFINITIONS community and position of insanity.

found its advocate in the person of Heinroth in the early nineteenth. however. though slowly. Bicetre. He established a retreat or asylum at York. quently these methods. Little by little. . chologic theories. were adopted elsewhere. though purely speculative way sible . and in which a rational Subse- and humanity were likewise the guiding principles. cruelty. of sorcery. for instance. Scientific conceptions as to the nature of insanity were like- wise very slow in developing. In 1793 Philip was appointed physician to the and substituted for a system of non-restraint and humane treatment Pinel blows and punishments. was not until the eighteenth century that any marked ad- vance was made. until long after the It dawn of the Renaissance. clothed in rags. William Tuke. and weighted down with chains. of insanity. and torture. badly fed. and witchcraft again held sway. This attitude of superstition continued throughout the Middle Ages. in Bethlehem. Tuke. metaphysic and psy- explanations began to take the place of religious The latter were finally definitely abandoned. At the same time that was making of the these great strides in France. advocated still The essentially sinful character by Stahl in the early eighteenth Century. lar who was not even a physician. a member Society of Friends. Various places for the custody and care of the insane were. in Rome. and the insane were subjected to neglect. made the Pinel advances. in America. and Benjamin first real Rush. and. but no real provision was their made for humane when care until the latter part of the eighteenth cen- tury. which care was opened in 1796. indeed. gradually established. began simi- reforms in England. and in the Hotel Dieu in Paris. in England. however. and physicians began to reason about insanity in a philosophic.18 MENTAL DISEASES demoniac possession. England. Pinel. The insane were still confined in dungeons. in France. science had not yet made posPhysicians were the framing of views based upon fact. in Ghent and Gheel in Belgium.

indeed. by the cell act of death That dendrites. poi- That the nervous system can be profoundly influenced by sons which leave no changes in their action of wake is shown by the various drugs. DEFINITIONS 19 slow to realize the essential truth that the insane reality. of insanity are They may be. implies disease. of the flow of ideas. apparently produce changes so slight as to be beyond our present ability to recognize them. this disease is the material organism. or should be so. in a sick man. organic or functional. of any or all of the manifold func- tions of the brain should ensue. the changes probably both slight and evanescent.INTRODUCTION. of the elimination of impulses. known of the action of such poisons as alcohol. either of the organism as a whole or of some special structure. It may be the direct outcome of some general always those of disturbed affection. and the mental those merely of exhaustion or symptoms may be from the action of may result poisons circulating in the blood. and that his symptoms must be studied just as we study those of other forms of disease. its vessels. Insanity. its attended by few or no demonstrable changes in the brain. Simiin- the mental symptoms caused by uremia. or so slight as to be effaced itself. in the nerve tissue are In either case. which cell modify nervous function and yet cause no change in nerve or fiber that can be demonstrated under the microscope. of a disease of the brain or of a disease of other viscera. of course. and that various disturbances of association. most frequently are. in short. That is this is not all a matter of speculation is shown by what Berkley. by thyroid toxication. membranes. can readily be conceived. man is. The symptoms cerebral action. or by the toxins of infection. just as do other of abnormal manifestations. Further. and the body should respond to the action of toxins. narcotics. and stimulants. and it is not surprising that this Insanity is at times purely symptomatic of bodily or visceral disease. . collaterals. larly. of sensation.

to various features. and tumors. Thus. these facts are will How as significant become more apparent we proceed in our studies. would appear that dendrites and son. it includes the disorders of sleep. trance. The wide scope of the subject and the relation which insanity bears to other states precludes a simple and formal definition. In general terms. and somnambulism.. and . includes the various forms of acute intoxication. such as the ears. such as changes in the nerve tissue. Most frequently they are evidences of arrest. insanity consists of abnormal mental action. chloral. etc. to the limbs. palate. In other patients unusual morphologic factors are noted. it includes much more than is ordinarily understood by insanity. In a small number of cases of mental disease. softening. alcohol. but at other times of pathologic deviations. abscesses. These may pertain to the skull. disease of the blood-vessels. This becomes evident as soon as a definition is attempted. gross or microscopic lesions are present. collaterals are actually destroyed or corroded It by the poi- would seem as though other poisons hkewise act upon these delicate structures —the minute threads of protoplasm represented fibrils by the collaterals.20 MENTAL DISEASES Andriezen. it it includes the delirium accompanying an attack of measles. and yet a brief consideration convinces us that this definition is too broad. and teeth. the dendrites. These morphologic peculiarities are surface indications of profound departures from normal growth and development of the organ- ism as a whole. and others have demonstrated changes both in the cell body and the amounts cell processes which result from the ingestion it of large of alcohol. is less and the neurodestructive —but that in most cases the action and induces merely changes of function rather than changes of structure. of the membranes. dreams. by morphin. or to the body. for example. chronic inflam- matory changes.

INTRODUCTION. at velopment previous the time of. The term sanity. is which is less pronounced not evident at birth or shortly after birth." and an imbecile as "an adult are. DEFINITIONS 21 these various manifestations of disturbed cerebral action can certainly not be classified cal among the insanities. . it is acting. they imply an original deficiency of mind. However." Both of these definitions of course. The idiot is one in whom is the mental loss is congenital of or nearly so. In idiocy the mental deficiency is the result either of disease or arrested deto. which are not. The idiot law takes cognizance of these as "one and has defined an who is born without mind. well to add that ordinary febrile delirium. "alienation" it is often used in the same sense as in- However. ficiency Imbecility deals with a mental dein degree. properly speaking. may be defined as a diseased state in which there is a more or less persistent departure from the normal manner of thinking. but they nevertheless embody the truth. embraces. l)y In order to discuss intelligently the symptoms presented the insane. while insanity is essentially a qualitative affection. and imbecility. besides insanity. child and only becomes apparent as the life. and sleep disturbances are not included. grows older or as it approaches puberty or adult facts. also idiocy insanities. Idiocy and imbecility are quantitative defects. or within a very few years following birth. a sometimes exacted on the insanity witness stand. intoxication. If occasion demands. and feeling. The imbecile one in whom the symptoms mental arrest make their appearance later. of it is necessary that we should have clear conceptions some of the terms by which these symptoms are designated. with the mind of a child. Under these circmnstances. is To the medi- mind a formal definition of insanity definition is neither necessary nor possible. excessive. Idiocy and imbecility are related conditions.

a human figure —when no such object is is present. or. perhaps best explained by a few A patient hears a bell ringing. g. be due to a defect or peculiarity of a sensory organ. the object perceived not properly apprehended and the impression is not properly correlated with previous Further. In an illusion. for instance." An illu- sion is a perception which is misinterpreted.. it Thus. an illusion may. tions. hallucinations of taste and or there may be various somatic hallucinations.— 22 MENTAL DISEASES is Fortunately their number of comprehension. In other words. as is the term is here employed. he hears the ticking of a clock. A hallucination It is roughly defined as a sensa- an object. e. no and no other sound vibrations have been present rise to which could give the same or similar sensations. but the object incorrectly interpreted. the patient sees it and mistakes for some other object. but such a mistake does not constitute an illusion in the sense which here concerns us. Contrary to hallucinations. bell is ringing. Hallucinations may affect any Thus. and mistakes the sounds for articulate words or sentences. Some an patients present what are termed "illusions. in an illusion an object is is really present in the external world and an impression is really made upon the senses. He mistakes a curtain cord for a snake. and . object. that ob- scure sensations referred to various parts of the body or to various viscera. or a rug upon the floor for a wild beast. such as the eye. impressions or experiences. hallucinations of touch." tion without illustrations. a hallucination a sensation which arises spontaneously in the mind without there being any object in the external world to of the excite that sensation. A mistake in perception may. of course. senses. is. in fact. or the patient believes that he sees some object an animal. when. not large and they are not difficult Many patients present is what are termed "hallucinations. we may have auditory and visual hallucinasmell. a chair. may be an animal.

in spite of his belief. It be- comes necessary. without qualification. and this we may do as follows: An insane delusion to a false belief con- cerning which the patient is unable accepted by ordinary accept evidence. but not of possessing insane delusions. A delusion more may than be roughly defined as a false but it is seen at once that such a definition. or it may evoke thoughts and feelings not normally in question. a his man may believe that neighbors have made holes in the walls of his house and that . Persons holding opposite religious views could reasonably accuse each other of holding false beliefs. both play an important role in the symp- tomatology of insanity. Patients also present what are termed "delusions.INTRODUCTION. should be added. Delusions are variously spoken of as systematized and unsystematized. a patient and. all is who all believes that he no longer has a mouth. demonstrations to the contrary. embraces far is intended. is A man who believes that his bones are broken or that he is is. and who is incapable of accepting the of course. possessed of the strength to move mountains. in error." belief. the victim of de- proof offered that he lusions. to accept the proffered evidence which gives rise to Thus. A i. therefore. excite or become associated with other sensations. It is this inability to accept evidence which is so striking a factor in the delusion of the unpardonable sin in melancholia. e. beliefs. such as is It is men or by normal minds. persists in possessed of a delusion. structure. DEFINITIONS 23 frequently does. This is also true of other pohtical and scientific. to qualify this definition. the inability the delusion. in the delusions of grandeur in paresis. systematized delusion is one which has a logical the various parts of the delusion bear a coherent or logical relation to each other. in the delusion of persecution in paranoia. Illusions excited it by the object and hallucinations. which men may is hold. large They are common symptoms in a number of diseases. thus..

indicative either of physical or mental greatness. here delusions which are fragmentary. or other quality of ex- cellence or greatness in the patient. fleeting. ies on the other hand. They may relate. that he billions about to marry the that he has the queen. Depressive delusions may be of two kinds. and may embody ideas tion. the patient may believe that he . and that he is destined to perform great deeds and great missions. systematized delusions do not complexity. All evidence of a logical structure is wanting. A depressive delusion. again. Unsystematized delusions are seen typically in delirium and confusion. under certain circumstances. of poverty. perfection. that is." Again. Thus. expansive or depressive. a man believes that will. though not always. first. In unsystematized delusions the reverse obtains. or he may beheve that his neighbors have entered into a conspiracy to believe that he is injure him. they may deal merely with the body. and unrelated crowd into the patient's mind. to the spiritual side of man. that his strength is super- human. give rise to the delusion of the "unpardonable sin. they are relatively simple. Delusions are also spoken of as An expansive delusion is one which embodies the idea of grand- eur. of unworthiness. that he is possessed of occult powers or of some other mysterious quality. of physical or mental wretchedness. that he a person of unusual consequence. As a rule. is one which embod- the idea of belittlement. was ever heard. of persecution.24 MENTAL DISEASES through these holes they shout curses or abuses. that he owns finest voice that upon billions. power. beauty. or of other qualities indicative of suffering. he is Napoleon. wealth. and the present much various parts of the belief are always in relation with each other. At no time is a coherent relation apparent. that all all people are subject to his is that he owns the ships upon the sea. of moral unworthiness and self-accusa- and may. he may is possessed of un- usual powers.

. and a neurasthenic patient a group of symptoms indicative of exhaustion and chronic fatigue. spiritual same and often it is not possible to separate them. is ill. require a ropathic. is applied to those fundamental deficiencies and aberrations of the nervous system which predispose disease it to disease. delusions Such may be spoken of as somatic or as hypochondriac. exist in the Very frequently spiritual and somatic delusions patient. The changes pathic states. Two terms which are frequently used in speaking of the insane moment's attention. ditions. Neurasthenia deals essentially with functional con- The word "neuropathic. DEFINITIONS 25 that his body is diseased. and is this tendency to degeneration which in the description of termed neuropathic. that he has a snake in his stomach. in the ductless glands. also. that he no longer has a mouth. it is transmitted from parent to child. will Other terms used mental symptoms be considered and defined as occasion arises. which has its origin in aberrant defective development. Some and peculiarity of structure. Neuropathy has basic morphologic and functional deviations and weaknesses. We but should remember. They are neurasthenic literally is and neu- The word "neurasthenia" means without one presenting nervous strength. as might be supposed. embrace the organism as a whole." on the other hand. it is largely hereditary and plays an impresent in neuro- portant role in mental disease.INTRODUCTION. ideas of unworthiness and bodily disease being intermingled. as a rule. that depressive delusions may relate neither to the spiritual nor physical makeup of the patient. may assume the form of delusions of persecution. in vascular supply. or in some other unknown quality which favors degeneration of is the nervous system. that his viscera have been removed. or that he has some hopeless physical ailment. and. or which of themselves its origin in entail and degeneration.

near an interpretation there enters every fact at our or remote —not only the symptoms presented by the patient. by symptoms. not only his family history and his personal history. or by the scanty all facts of pathology. no matter all of which category they are found. and into such disposal.CHAPTER II CLASSIFICATION Pathology has as yet so little to offer that we must content ourselves with a purely clinical interpretation of insanity. not only philosophic of our and but is necessitated by the condition knowl- edge of the subject. and of the course. we are guided not by a or single series of facts such as are presented by etiology. scientific. there- fore. clinical interpretation is A it is not only of practical value. we weigh facts. that we explore verging avenues of truth the con- —in short. 26 . not only his sex. and the prognosis of the disease in similar cases. the duration. epoch of fife. but also interesting and scientific. In attempting a classification of insanity from the clinical standpoint. all presupposes that we approach that the subject from all posin sible points of view. but It by of these and others combined. and it gives rise to clear and logical con- ceptions in a field where confusion and uncertainty too often prevail. or but all that we know of the changes in the tissues. The clinical interpretation of a disease means literally its bedside interpretation. his age. that we take into account Such a method is everything that enters into the natural history of the disease we are about to study.

the morbid state which most allied to delirium is which confusion found is less active but more prolonged. A child it is has an attack of fever. medicine. confusion and hurry fleeting and fragmentary delusions. clusion alike. restlessness. abnormally aroused. This picture. that cries out. illusions. struggles. seen typically in the con- . has seemed to me most natural to begin the study of mental disorders with the affections with which the general practitioner first comes in contact. There are present of thought. or. a closely week or two. so familiar. its At the same time. is no matter what its origin. For instance. This the case whether the delirium occurs in a young or an old it person.CLASSIFICATION I 27 have long come to the conclusion that insanity must. and yet the fundamental is symptoms are always the same. though perverted. incoherence. as in alco- deHrium in which visual hallucinations predominate. it does not recognize its surroandings. its cries. whether be mild or whether it be severe. acts as though it heard its strange sounds and saw strange objects. broken and hurried words indicate that is the cerebral activity. is the picture of simple delirium. that it that it shrinks. Such a state in the prolonged con- fusion which every now and then comes on It is in infectious dis- eases after fever has subsided. as be approached from the standpoint of practical it far as possible. hallucinations. and the physician observes that confused. of rela- Delirium is essentially an acute mental confusion a few days. at is tively short duration —a few hours. no graduate of medicine practices long before he comes in con- tact with such an elementary phenomenon as delirium. one in is most. We soon find that these elements are present in every form of delirium. Naturally. and our all first logical con- that in these essential particulars is of the deliria are It perfectly true that some of the deliria present special features holic dependent upon their causation. Indeed.

erysip- acute articular rheumatism. sanity and the In confusional in- —the amentia of Meynert. second. may . but cerebral activity and. special forms may bear the impress of their causation. never roused to the same high pitch. until finallj^ the faculties are completely in abeyance. profound and persistent exhaustion. surgical shock. a confusional insanity following typhoid fever presents a somewhat different clinical picture from the confusional in all essential insanity of alcohol. or profoundly debilitating cause tal confusion. Into its causation. influenza. confusion may last many months. more or less marked mental confusion. followed poisoning. particulars they are the same. and. while deUrium lasts from a few hours to a few days or more. How- ever. and no sharp distinctions can be drawn between them. and in which. Such a case forms one of stupor or so-called stuporous insanity or acute dementia. the same marked confusion and incoherence. as is well known. of several Generally there a prodromal period suffers it days or weeks during which the patient from be. trauma. The various forms of con- fusion are closely allied to each other. Simple stupor. the Verwirrtheit of other German and writers —there is is the same presence of hallucinations delusions. by little.28 fusional elas. is is by men- but in which the confusion accompanied with little very marked dulness and hebetude. does not is make its appearance suddenly. attended. mental obtusion becomes more and more pronounced. etc.or lead-poisoning. Its symptoms do not differ in any essential particulars from those of delirium. the toxins of infection or other poisons. profound ex- haustion. MENTAL DISEASES insanity following typhoid fever. and yet Every now and then we meet with cases in which an infection. the puerperium. there enter especially two factors: first. just as are the deliria. save that they are less acute course of the disease far more prolonged. Thus.

the patient at As first suffers from insomnia. separate and we will see. the patient believes himself to be in a strange place and does not properly distinctly hallucina- recognize the persons about him. at times impossible to accurately characterize a given case. He is also Little and up to this point the case resembles one of confusional insanity without much excitement. As in ordinary confusion. it Every now and then happens that a case beginning as a simple it is delirium merges into one of confusion. cases are met with which occupy such are obUged to term an intermediate position that we them cases of confusion with stupor or stuporous confusion. of the interrelation of delirium and confusion. from other . is What true of the interrelation of confusion and stupor is also true.CLASSIFICATION 29 in the beginning of con- with excitement or with depression. of place here to dwell further would be out of stupor. fusion and stupor are indeed. tory. Soon con- makes its appearance. delirium. secondly. There now no longer confusion. motionless is in bed. as by themselves. noticed in the beginning. I upon the symp- toms wish merely to emphasize the fact that conclosely related clinical forms. and soon the loss of the power to appreciate the surroundings belies comes so profound that the patient oblivious to everything about him. becomes more and more marked. stupor may occur as an episode of confusional insanity. and fusion is unable to think clearty. It is. There is loss of the proper appreci- ation of the surroundings. fusional insanity. by little mental ob- tusion. and. is worried and afraid. and they may be considered as constituting a group of mental affections distinct. but instead a more or less complete suspension of mental action It —stupor. and also true that during the course of a confusional insanity episodes of more or less active delirium may supervene. I need hardly say. Clearly. con- fusion and stupor are closely related clinical forms. In the first place.

incoherence and confusion. one after the other. confusion. As pointed of out. through both of these phases. The symptom group from that of melanchoha-mania differs. delirium. as ical history of the great majority of cases. whether be mania or melancholia. We have. in the phase of mania. As our studies progress first. melancholia. is. emotional depression in mania. plays only a secondary role. for example. is probable that in delirium we have especially and essentially such an action. differ In these respects. we will recognize that they are closely related to each other. and sec- ondly. we will learn. and of other upon the cortex. namely. I MENTAL DISEASES will not here deal with the causes of delirium. and stupor radically from the next group of mental diseases to be consid- ered. Heredity also plays a most important role. confusion. illusions. or stupor. confusion. confusion. of subsidiary importance. pursues a wave-like course. and will stupor. mania. in the clinical A sufficient hint is afforded us history. though may be disturbed. and stupor are closely related forms. that heredity in this group. and first we construct of them the group of our classification of less mental diseases. of course. while fusion and stupor in con- we have the added factors of exhaustion and secondary changes in metabolism. tion. radically of delirium. through a phase of emotional exaltation. it is a striking factor in"the clinFurther. Here the emotional state dominates the entire clinical picture and outweighs it all other symptoms. In melancholia the patient passes through a phase of .30 mental disorders. of bacterial toxins. in addi- two important it facts: that the emotional state. and in circular insanity. as we . they are more or characterized by the presence hallucinations. we study these affections. We It have at once suggested to our minds the action poisons of the bacteria. the affection. The above considerations show that delirium. unsystematized delusions. and circular insanity. Secondly.

" Melanchoha-mania affections heboid-paranoid in group are which are essentially neuropathic their nature. The individuals who suffer from them are essentially defective in their make-up. in melancholia. us repeat. Among the younger patients this gives rise to the various forms of juvenile insanity. ation. but the disease tends to repeat still recurring waves. As a until rule.CLASSIFICATION learn farther on. In our scheme of classification they constitute the second group. the tendency is to recovery from individual atitself in tacks. of Following the lead of Kraepelin. psychic inhibition. we may speak Further. The of individual appears to be able to adapt himself to the strains in greater or less degree until life a certain period of his career. physical and mental. by reason of his defective organization. them collectively as manic-depressive insanity. depres- sive delusions. he breaks down. emotional depression. of delusional lunacy. let The members of this group are characterized. an expansive emotional an increased ra- pidity in the elimination of ideas." while the delusional lunacies are con- veniently embraced under the term "paranoia. associ- an absence of hallucinations. Allied to them we have still another group. "the heboid- and may be classed together under the general term and the paranoid group. 31 state. also neuropathic. they present after no symptoms which attract attention some time is puberty has been passed or until youth or adult age reached. an abnormal increase of fleeting. has been the custom to group the juvenile insanities under the general term of "dementia prsecox. in this group. expansive delusions. among the older. when. . In another group of mental diseases we have to deal with affections that are essentially degenerative in their nature." insanities The juvenile and the delusional lunacies form a natural group. to various forms it Following Kraepelin. by a dominant emotional state and by a wave- like course.

The Dementias. as in the heboid-paranoid forms. The Heboid-paranoid Group (Dementia noia) . group. from simple mental as a simple and loss. Prsecox. nor a downward or degenerative course. Dementia may is exist uncompUcated condition. III. as in manic-depressive insanity. . Melancholia. and frequently seen in its pure and typical form in old age. Of late years.. of deficient control of impulses. Mania. dementia.32 MENTAL DISEASES is which made up of mental disorders in which neurasthenia essential roles. and neuropathy together play the There is here neither a wave-like course. The term "neurasthenic-neuropathic" little more expressive. but merely a symptom group characterized chiefly by weakness and defective inhibition. I. inasmuch as the expression "soul weakness" can hardly be regarded as convejdng a definite conception.) V." which the writer. (See Chapter VI. The five groups of mental affections above enumerated are inter- fundamental and are necessary to a comprehensive pretation. it is necessary to add still a fifth i. insanities resulting e. II. Manic-depressive insanity). Stupor. Para- IV. namely. of chronic indecision. They are as follows: Delirium. following Janet. though perhaps a it awkward. regards as open to objection. Confusion. These disorders may manifest themselves in the form of abnormal fears. Circular Insanity (Melancholia- mania. The Neurasthenic-neuropathic Disorders (Psychas- thenia. or of deficient will. To this group the term "neurasthenic insanities" was long ago applied is by French writers.) In order to make the clinical view of insanity complete. however. has been the custom to employ the term "psychasthenia.

and. lastly. Finally. and also insanity by contagion. we will consider briefly certain mental diseases not usually included under insanity. . to infancy. practically We will consider the relation which insanity bears to the various infectious diseases. early adult age. study the subject as related to the various epochs of namely. to the diseases of the nervous system. puberty. and lactation. to the various diseases of the viscera.CLASSIFICATION In the course of our studies 33 next consider insanity is we will from the point of view of internal medicine. to the disorders of metabolism. and old age. mature adult age. We will further life. this of great importance. the puerperium. to the intoxications. to pregnancy. middle age.

is frequently under the observation of it Once comprehended. in- coherence. though they differ in their details. and the various acute visceral diseases. somewhat They naturally separate themselves into two groups. occurs common epiphenomenon of fevers. the exanthemata.CHAPTER III GROUP I—DELIRIUM. intoxi- cation and exhaustion. physical restlessness. If always of short or relatively short duration. such as pneumonia. therefore. We have already enu- merated its principal features in the preceding chapter on Classification (see p. by a All deliria are essentially alike. asked to define "delirium. fragmentary. These were illusions. STUPOR Delirium. The afebrile deliria may have 34 their onset during the period of convalescence — the . cerebral excitement. falls It is. characterized may say that it is an by the presence active men- of illusions. unsystematized delusions. as a result of various intoxications. and relatively short course. hal- lucinations. a condition which the practitioner. after trauma or shock. To these must be added ex- aggerated cerebral activity and physical restlessness. explains much that met with in the allied states of confusion and stupor. infection. the as a very first member of this interesting group. The and afebrile deliria are those which are met with as sequelae of various infectious diseases. and unsystematized delusions." we tal disturbance. are those which The febrile deliria accompany the various acute infections. hallucinations. fleeting. the febrile and the afebrile forms. 27). CONFUSION. delirium is Further.

acute delirious mania. they may make their appearance in lead. SIMPLE FEBRILE DELIRIUM Etiology. for instance. septi- pneumonia. I 35 example. and Bell's delirium. and a rational hypothesis to ascribe like properties to the poisons resulting from infection. local and visceral. erysipelas. Simple Febrile Delirium. It typhomania. The gests classification which a consideration of the deliria sug- is. ture and the circulatory The elevation of tempera- and respiratory disturbances accompa- . influenza. — Simple febrile delirium is always accompanied in addition to the elevation of temperature —by physical in signs. cemia. Afebrile Delirium. STUPOR period — of one of the exanthemata. Specific b. we must include a deis lirium that has been described as a special form. small-pox. 2. Febrile 1. acute articular rheumatism. pyemia. such as are found in pneumonia or by other accordingly indications of infection. It is probable that in these affections the delirium is directly It is due to the action of toxins upon the cortical neurones. tuberculosis. clinical entity. cases of poisoning." To its consideration we will presently return. and variously known as delirium grave. for typhoid fever. CONFUSION. by visceral changes. acute delirium. from alcohol or Under the head of the febrile deliria. the following: a. therefore.— GROUP postfebrile —DELIRIUM. Delirium. It is met with typhoid scarlet fever. Febrile Delirium. well known that poisons introduced from without it is may produce delir- ium. Again. such as an eruption or other evidences of the exanthemata. appears to be a special of as "specific and may with propriety be spoken febrile delirium. measles. and various inflammations. fever.

or such as lessen the and alcohohsm individual powers of resistance. however. This feebleness of resistance is most frequently associated with his- a neuropathic family history. sometimes with a personal tory of frequent illnesses with delayed convalescence. certain In other words.36 MENTAL DISEASES nying the infections may also play a role as causal factors. or with other factors indicating weakness. . such as tuberin the ancestrj^. patients become in delirious under sUght provocation. of course. The reader must not. is highest. and there must be them a feebleness of resistance. infer from these statements that the ocis currence of febrile delirium indicative of a neuropathy. and perhaps upon the bodies. finer collaterals The toxins probably act later first upon the cell and dendrites. It is. though this role must be subsidiary in character. To this explanation must be added another factor. known that the occurrence of delirium varies greatly ent individuals. while mild febrile attacks are occasionally accompanied by dehrium disproportionate in intensity and degree. a prone- ness to mental disturbance not observed in normal persons. notabty alcohol. act as predisposing factors. exciting. this is and becoming milder probably because the when the temperature but higher temperatures are consonant with higher activities of the infectious processes. inhibiting. culosis either hereditary or ac- Any causes that weaken the stock. repeatedly encountered without delirium It is well in differ- Severe infection and high temperature are of moment. being greater when the temperature falls. especially the abuse of poisons. it is well known that cir- active delirium may exist without fever and also without culatory and respiratory disorders of moment. a matter of common experience that the intensity of a febrile delirium varies largely with the intensity of the fever. and otherwise perverting the func- tions of these various structures. quired.

the persons about him. CONFUSION. disturbed. and can be readily recalled to himself. Symptoms and Course. foot-falls. animals. as is more or less evidenced by the patient's manner and the phrases and smell. At times. all give rise to illusions. . are. become delirious under the influence of febrile infections. is and even at times The onset may be is preceded by restlessness. Indi- vidual attacks differ greatly in degree. and food that is fails to recognize the drink or offered. neuropathic factors are found in only a percentage of cases. the attack so slight that the patient appears merely to be wandering or half-dreaming. The patient mistakes the objects in his room. sleep easily. Persons otherwise entirely healthy may. nor can his attention be readily its Very soon excitement makes appearance and may make increase. At first he can be recalled to himself. Tactile illusions. their appearance. the patient misunderstands the at- tempts at handling him. illusions of taste appear also to be present. . that escape him. The nurse. be- strangers or strange beings. due partly to the character and intensity of the infection peculiarities of the individual. and figures are seen. the patient becoming noisy. it may be extreme. or other relatives. the opening and shutting of doors. Sounds are equally misinter- preted the voices of friends. as the case may be. STUPOR 37 indeed. and it is only in cases in which an unduly severe or intense delirium attends a mild infection that neuropathic factors are indicated. the patient dull. Most frequently it is more marked. it is unneces- sary to add. the figures upon the wall-paper. of course. usually with the rise of the temperature and the develIllusions opment of the other symptoms of the infection. and at times violent. phantastic forms. he does not comprehend held. come the mother.GROUP I —DELIRIUM. noises in the street. the —The symptoms of the and partly to is febrile deliria same as those of delirium in general. destructive. Instead of the furniture.

battles are being fought. to be very short-lived. betrays by smiles and gestures. diversified. however. children are being is tortured. Every now and then a lull is observed in the violence of the sjonptoms. a stage which proves. Houses are on people are being killed. soon. and upon the feebleness or strength and in estimating the significance of delirium in in a given case both these factors must be borne it is mind. a more decided complication it is in some affections than in others. the defirium becomes more marked rise of the temperature and the advance of the infec- tion. As already with the indicated. and hallucinations and delusive ideas compHcate the picture. for soon the painful and terrifying hallucinations and delusions again assert themselves. painful. by expressions of pleasure or rapture. he rections. instead of being frightened. monly the delusions fire. changeable. Further. however. thus. The intensit}'^ of the delirium depends both upon the severity of resistance of the infection of the patient. and the delusions which the patient manifests are correspondingly varied. however. may still comply with requests and illusions di- Soon. pressions and spontaneous The hallucinations rapidly become numerous and soon they play the leading role. the . The patient can no longer be brought to a reahzation of his surroundings and reacts entirely to his perverted imsensations. Quite comdistressing. it ceases to keep pace with the latter. commonly more pronounced in typhoid fever than in any other of the exanthemata. dismembered bodies and other visions terrify him. the violence of the symptoms abates. or the patient. that he is in a stage of exaltation. and fleeting.38 MENTAL DISEASES realize that and be made to he is ill and to understand what is being done for him. the excitement lessens. are frightening. the patient compelled frightful to fight for his life. the become more pro- nounced.

of course." knoAvn by a number of synonyms. or a muttering delirium. Prognosis. more readily sometimes than the diagit is nosis of the disease of which an accompaniment. the restlessness of which expresses at the bed-clothes. cance. the or stupor. In severe cases. some degree of mental weakness persists for a time.GROUP I — DELIRIUM. The term seems to me to be especially applicable. as already stated. in which. secondly. thus. mental weakness may for a time persist. or less open to objection." although it is in no sense a mania. w^hich I is have myself termed "specific febrile all. because are spoken of as "acute delirious mania. sometimes for months or even for years. Diagnosis. factor. though they both lack a distinctive "specific febrile delirium" signification. the prognosis quite favorable. is may then indicate a very grave infection what equally ominous. made. save in a very small percentage of cases. itself by a tugging or picking becomes established. I delirium. it is not definitive. is spoken of as "acute all deliria delirium" a term which acute." The names "Bell's plies to the older term delirium" and "delirium grave" are somewhat less objectionable. the same objection ap"typhomania. however. Rarely. The affection is distinguished from ordinary febrile delirium by the fact that there are never present any . it is believe. feebleness of resistance on the part of the patient. febrile delirium is. STUPOR 39 patient becomes clear or relatively so. the patient's mind becoming entirely normal. —A febrile delirium is quite it is commonly a it negligible Only when It unusually severe does acquire signifior. CONFUSION. As is far as the mind of the patient is concerned. patient all may pass into a condition of coma Usually traces of delirium disappear when the infection has spent its force. readily —The diagnosis of a indeed. SPECIFIC FEBRILE DELIRIUM The more affection.

sented by both the family and the personal histories of the patient. Sometimes. lassitude. that neuropathic features are frequently pre- is said. while there are not present in the exanthemata. trauma. varying in duration from several hours to a day or more. its Soon. grief. though It this hardly accords with the experience of the writer. any surface lesions such as are found nor any sign of visceral involvement. The very number and of acter of these factors rob them any specific value. It would appear it also from the statements of several writers that occurs more frequently in women than in men. usually within twenty-four hours. tinnitus. Etiology. and but It appears to little is known relife. Specific febrile delirium together with an intense delirium.40 physical signs. a delirium makes . and bad hygiene. Narrowness of the pupils has also been noted. —The onset of the disease this is usually very rapid. headache. also. such as pneumonia or meningitis. its etiology.— It garding is a rare disease. During time there may be present in- somnia. a prodromal period has been noted. irritability. excesses. may be defined as a delirium. they could only act by diminishing the resistance of the nervous system to toxic or infectious processes. and could not of themselves play any role other than that of secondary or predisposing causes. weakness. and perhaps uncer- tainty of gait. be an affection of adult occurring most frequently between twenty-five and forty years of age. however. the rise of temperature being generally quite high. characterized by a febrile state. often sudden. are made and debilitating depressing emotions. intolerance of light and sounds. Other equally vague and unsatisfactory statements in regard to the previous existence of exhausting affections. S3niiptoms and Course. anorexia. very active. char- fatigue. MENTAL DISEASES merely a high temperature.

and the patient appears mercy and rise. From his fragments of sentences. be brought in any degree to a realization of his surroundings. food and drink can rarely be ad- ministered. As might be expected. anguish. in the intervals of his struggles he in a continual state of agitation. or lips issue may. blood. He struggles. at times a mouthful may . anger. terror. He may spring from his bed. Indeed. of his hallucinations. which rapidly assumes a great intensity. tries to escape or to hide. Paroxysms of terror associated with staring eyes. as are the disordered ideas to which they give of and.GROUP I —DELIRIUM. broken phrases. shrieks. laugh or smile. even illusions to be entirely at the are not formed. sings. He is picking or pulling with his air. and the phrases the patient fire. shrieks. or certain groups of ideas. throw himself against the walls. or attend- ants. painful terrifying. and constantly moving unless restrained. only to be suddenly ejected. hands. the food may be retained in the mouth for a mo- ment. shouts. painful in the extreme. half-articu- lated words. and tortures. but no coherence or systematization obtains. of torture or poisoning. the symptoms resemble those ordinary febrile delirium. the patient raves. utters. are of murder. he weeps. furious in character. such as of and of being burnt alive. often under- stood with difficulty. his fea- tures express in rapid sequence fright. he cannot. furniture. Certain ideas fire may recur. He is entirely obtunded to his surroundings. save that they are magnified and accentuated. as in deliria of less violent form. in this respect. grasping at the pushing away or warding off imaginary dangers. STUPOR 41 It is appearance. for brief intervals. tearing at his clothes. of a torrent of The ideas reveal no sequence other than that disordered and fragmentary delusions. and mad struggling can only depend upon frightful hallucinations. ecstacy. CONFUSION. in the main. may pre- dominate. The latter are. The patient's restlessness is is extreme.

as a rule. rarely slow. F. Even when introduced forcibly by the stomach-tube. and occasionall}^ hyaline casts are found. The bowels at first are obstinately con- but later. indeed. it may not be retained. the patient be marked. quency and are sometimes the attack they toward the termination of may assume a Cheyne-Stokes character. due aUke to the struggling and to the is anorexia which undoubtedly present. The saliva appears to be increased. this defer- vescence does not take place. Sweating also may though later the skin becomes The affection pursues a rapid course. The and pulse is rapid and of high tension. The breath is foul.. a characteristic feature of the disease. and ranges a time in the neighborhood of 104° F. colored. It often attains 105° and even 106° death. very respirations are also increased in freirregular. The temperature . If death does not soon supervene lapse — it may take place as early as the third day — col- makes its appearance.42 MENTAL DISEASES it is be gulped. stipated. and finally gives way to stupor. albumin may be present. and the patient. of the patient is The temperature high fever is always elevated. It it soon becomes small irregular. The delirium becomes low and muttering. as exhaustion supervenes. The scanty and high The chlorids are diminished.. an offensive. struggles against it. already having ideas of poisoning or torture. impossible to get the patient Food is not recognized. more frequently to take anything. drool freely. the tongue becomes heavily coated and the teeth covered with sordes. the high temperature persisting until death ensues. may first. especially at dry. is it may The vary from 120 to 140 per minute. and persists. until shortly before fall. urine is colliquative diarrhea sets in. when it may rapidly at times. however. rises to The for temperature rapidly 102° or 103° F.

Pathology. Usually. membranes and vessels. indeed. The neuroglia may reveal evidences of prolifera- . deformity. together with varicosities of the enlargement of the nucleus. cell processes. there is also wasting of muscles. occasionally complicate the picture. g. the brain. may here and there be adherent. The subdural space and the meshes contain an excess of cerebrospinal of the pia-arachnoid fluid . A microscopic examination the cells of may reveal a marked chromatoly- sis of the cortex. attack The entire duration of the it may be six or seven days. at times the nails are general emaciation extreme. and section of the brain substance opalescent. being entirely normal to the naked examination reveals a eye. though cases of two and three weeks have been recorded. —the hair may is out. that recover. or there may be evidences of infiltration along its it vessels. displacement of the nucleus. rarely does extend over a longer period. The pia may be stripped off the convolu- tions with unusual ease. and here and there tions marked engorgement or even slight hemorrhagic exuda- may be noted. the features pale and shrunken. it At other times the pia may be slightly distinct tinge of red. In the very few cases tedious and difficult. general or local in character. Similar changes have been noted in the cells of the cerebellum. instead of being abnormally loose. STUPOR 43 becomes subnormal. —A postmortem examination its may reveal nothing whatever. the convalescence in other exhausting affections fall is As e. and. may the vessels of the pia may be full of blood. and cord.. typhoid fever lost. and death ensues from exhaustion. may may present a reveal a finely punctate appearance. CONFUSION. Convulsive seizures. together with shrinkage. even spontaneous gangrene may supervene. the macroscopic injection of the marked hyperemia and membranes and cortex. however.— GROUP I — DELIRIUM. the medulla.

in a meningitis. pneumonia. together with the presence of a delirium of rapid evolution and great intensity. especially MENTAL DISEASES about the vessels. meningitis. others such as Cabitto. should suggest In other at once the existence of specific febrile delirium. accompanied by high temperature. special course. no doubt of the existence of one of the eruptive fevers. some most probably the toxin is some infection. of course. no specificity could be ascribed. articular rheumatism. and diplococci.44 tion. streptococci. However. to which obviously still. or of pelvic. the evidence at hand factory. is The clinical picture is always very different. or other local lesions. as a rule. It is impossible. it is not impossible that a syndrome which may be the outcome of diverse infective agents. other have noted the presence in the blood of staphylococci. its nuclei may be increased and its network more pronounced. its its symptoms. the delirium . in the present state of our knowl- edge to form a definite opinion. abdominal. erysipelas. that pre- sents special features as regards its evolution. have failed in undoubted delirium grave to find any microbic infection whatever. affections. and as such it demands study and consideration. the history of a period of invasion and the signs present at the time of the evolution of the delirium leave. it must be it admitted that delirium grave a clinical entity. However is this may be. as yet extremely meager and unsatis- Bianchi and Piccinino have described a bacillus is found in the blood of delirium grave which deliria. it is Indeed. thus. to indicate the action of of The changes observed seem poison. —The absence of the physical signs of the exanthe- mata and of the visceral diseases of infectious origin. or even to determine whether delirium grave is a specific infectious disease. Again. not foimd in other and which they believe to be observers specific. and its termination. Diagnosis. However.

a case of alcoholic delirium (delirium tremens) might. signs of alcoholism. restlessness but little marked. Postfebrile Deliritim) Etiology. CONFUSION. in mania. ocular involvement. of course. AFEBRILE DELIRIUM (Delirium of Exhaustion. is Rarely one of the exanthemata ushered in by a high temperature and an active delirium. such as typhoid termination. because of its intensitj^ suggest specific febrile delirium. besides the alcoholic history and the evident coarse of the lips. —As has already been pointed out in the study is of the sjrmptoms. but Again. In such in- stance. superlife venes before the fourth day. and then an active delirium occurs as an episode in paresis rarely. in rare instances. A few cases only survive. though. that there near a sudden defervescence of tempera- . The temperature is in the former is rarely pronounced. local or general. sixth. palsies. STUPOR is 45 much less pronounced. seventh day.GROUP I —DELIRIUM. now or. and. the great preof visual hallucinations. especially. and the and symptoms leave room for doubt. and. Death. may be prolonged to the fifth. especially an infectious disease. or. dominance is In practice no difficulty experienced in differentiating the various toxic deliria from the specific febrile form. Here. of its — Every now and then is it happens during the course fever. as already stated. suffice to make the differential diagnosis. convulsions. as a rule. we have the tremor the tongue and limbs. Similarly. the history of the case and absence of high temperature. vomiting. while there are present intense headache. the delirium clinical history much little less active. and the other signs unnecessary to enumerate here. every the subsequent course early solves the problem. for longer periods. as more an episode in a case of mania. Prognosis. the prognosis of specific febrile delirium grave in the great majority of cases. the presence of the physical signs of paresis. especially when accompanied by fever.

Delusions. soon. MENTAL DISEASES and that this is either accompanied or followed by an attack of dehrium. he becomes hallucinatory to an extreme degree. become animated objects. it may be that the infectious dis- ease from which the patient suffers has pursued and completed a normal course. for example. also. and fright. The individuals about his bed are no longer properly recognized. As in other forms of delirium. The pictures upon the walls. restlessness may make their Consciousness becomes much obscured. There is great emotional shock. may supervene. if the attack be severe. and that the patient has entered the stage of convalescence. day or two insomnia and an ominous appearance. the hallucinations which manifest themselves are varied and nu- merous. —The onset usually sudden. may occur during a sequel in the various exanthemata. and. afebrile delirium it may occur or as in widely separate affections. in the puerperium. in pneumonia. call to may become very pro- nounced. painful. all the curtains upon the windows. or animals. surgical shock. Thus. persons. he becomes illusional.— 46 ture. in sudden hemorrhage. and frightful fire. delirium. present in some cases in which such a delirium occurs an undoubted predisposition to mental disturbance this is —a hereditary less neuropathic cases. in typhoid fever. strange figures beckon to or terrify him. in influenza. and in various other conditions in which sudden exhaustion labor. when the latter is interrrupted by an attack of As might be expected. chairs The and other objects in the room are mistaken for strange shapes. Voices the patient. assassination —crowd in hurried frenzy through his mind. Thus. the rugs upon the floor. delusions of torture. poisoning. everything seems strange and changed. the patient loses the proper appreciation of his surroundings. fragmentary. Again. make-up —but probably true of than half the is Symptoms and Course. His struggles are those of . though at times prodromal symptoms for a may be noted.

The The small. difficulty. soon giving or terror. I —DELIRIUM. or making aimless gestures. and. pronounced. such a state always of brief duration. physical condition is indicative of great pros- surface of the body is cold. the movements become purposeless. Incontinence. tration. It is generally impossible to obtain a rational answer to a question. also. usually Afebrile dehrium last is an affection of short duration. the with great mind becomes more and more obtunded. though sometimes. takes his food. unless induced means. as a rule. but at times broken in upon by recurrences of . the patient turning about the bed. He may talk loudly. is indicating a pleasurable or expansive state. the struggling senseless and automatic. STUPOR 47 and though at times we note a smile. as can readily be surmised.GROUP fear. way again to signs of fear The speech of the patient. it It may only a few hours. during a momentary lull. never extends over more than a few days. is abohshed. and moist. Not infrequently the return to is lucidity is quite rapid. and his delusive ideas are difficult cries if not impossible to follow. Sleep. of the nurse. Food and medicine are administered As the delirium progresses. pulling and pushing. a laugh. or his speech may be entirely incoherent or consist of senseless repeti- tions or alhterations. The patient out or utters merely parts of sentences or phrases. the recovery it is unin- terrupted. the patient may comply by artificial with a given direction. begins to sleep. or a grimace. or he may whisper. pale. is cular weakness present. and. The patient begins to comply with the directions above all. Recovery is manifested by the gradual return of the power to recognize the surroundings. is for the most part fragmentary and confused. gesticulate. excitedly. CONFUSION. The Mus- pulse is sometimes slow. more is frequently rapid. or make grimaces.

The exhaustion lessens the resistance of the nerve-centers to the toxins of the infection —toxins which are Specific probably being imperfectly eliminated or otherwise slowly disposed of. we observe a gain in the physical condition and a disappearance of the restlessness. have not been described. changes in the nerve-centers. these symptoms. During the convalescence. role —Undoubtedly. together illusions. that changes of moment take place in the nerve tissue. little The patient remembers very of the attack. third. and which are cumulative in their action. are usually remembered very imperfectly. of First. usually transient in character. trauma. indeed. in the production of the afebrile deliria: exhaustion. the intercurrent delirium of paresis. the history of an antecedent a shock. of sudden hemorrhage. is It unlikely. may note that the patient All of is or excitable. second. signs of a sudden and acute physical prostration. two factors play the leading first. with marked obtusion and the obvious presence of hallucinations. and unsystematized delusions. Such matters as he does remember Pathology. attributable to the delirium. the rapid appearance of excessive restlessness. finally disappear. Epileptic deUrium is to . we emotional.48 MENTAL DISEASES Along delirium or confusion. with the other signs of improvement. fourth. the absence of fever. and second. toxemia. mental confusion with marked excitement and abnormal rapidity in the flow of ideas. —The features upon which the diagnosis : is to be based are briefly as follows febrile disease. irritable. cases very infrequently come to autopsy. usually nothing of the height of the attack. and from confusional insanity. Diagnosis. alcoholic delirium. because of the prompt and speedy recovery ensuing in most cases. or other acutely debilitating cause. Afebrile delirium must be differentiated from epileptic de- lirium. though they may persist for several weeks.

Prognosis. the ultimate in the majority of cases. indeed. rarely the delirium does not subside precarious. of CONFUSION. by the greater intensity and activity of its symptoms. STUPOR 49 be differentiated by the history of epileptic seizures. however. it In its more active and pronounced forms. presents ical itself under various clin- forms. more rarely the delirium eventu- ates in a stupor which Ukewise proves of long duration. and the patient passes into a condition of more or less persistent confusion lasting for a variable period. In outcome is one of recovery CONFUSION Confusion. lirium. all. by the absence of the physical by the complete loss of consciousness. The large majority of cases recover. and especially by the predominance is of visual hallucinations. delirium is —Other things equal. signs of collapse. completely. Still some- times for many weeks. by the presence of the physical signs of alcoholism. may be so slightly pronounced. is Delirium tremens to be differentiated by the history of alcoholism. closely related. and by its rapid and short course. and as Verwirrtheit. by the absence of an antecedent history of febrile or other exhausting disease. 4 resembles and. usually obtainable. . The prognosis is is grave only in cases in which the physical condition Again. also spoken of as confusional insanity. by the absence a history of antecedent febrile or other acutely debilitating cause. however. the prognosis of afebrile good. both mental and physical. either case. The intercurrent delirium of paresis to be distinguished signs of paresis. approximates deit On the other hand. is by the histoiy of the case and the physical From by its confusional insanitj^ afebrile delirium to be separated stormy development.GROUP I —DELIRIUM. as amentia (Meynert). and by such phenomena as epileptic automatism.

However widely the forms of confusion differ from each There other. the underlying features are always the same. namely. perhaps feebly sys- tematized. fections. so may on the other hand. In the more active form. with the and toxemia. activity it. Delusions unsystema- tized in character. and especially in its less active forms. rheumatism. just as does afebrile delirium. and recog- we at once add clearness to our clinical conceptions nizing at the outset the existence of these widely differing forms. approximate stupor. just as confusion when attended by marked and ex- citement may approximate delirium. so as to suggest stupor. that only a state of mild mental confusion may be present. are present in almost all cases. as —In the etiology of confusion. it may follow typhoid in- pneumonia. indeed. Again. illusions in conse- quence. as to objects. are so only in the more active forms. puerperal allied conditions. confu- . surroundings. deal. and At other times. active confusion and passive confusion. may be absent. we have to two factors of exhaustion in delirium. the confusion stands in undoubted relation to the infections. in the forms which approximate stupor they Etiology. Hallucinations. active form of confusion The by less may properly be termed passive. or in the passive forms. it may be so light as to be represented by merely a slightly dazed state of mind. influenza. fever. if and persons markedly may be observed. variola. erysipelas. and it not infrequently occurs during the convalescent or postfebrile period of the exanthemata. present.50 the MENTAL DISEASES symptoms so mild in degree. acute articular Thus. in the active form haustion — —the perhaps as a result of increasing toxicity and expatient may become very dull and heavy and In other words. his confusion very deep. is always present some degree of mental obtusion.

GROUP sion I —DELIRIUM. is In about one-half the cases. may be the result of a gastro- on the whole. the proportion of cases of confusion is relatively small. though. confusion intestinal intoxication. is due to toxins formed in these organs. There is also reason to believe that. such and rheumatism. this the case with alcohol. Part II. that becomes evident many of the causes indicated. especially the infections and the auto-intoxications. at other times. to a failure of elimination of substances normally present in the body.) Their discussion here would lead us too far it In considering the etiology of confusion. such an etiology appears to be infrequent. (See afield. Taking into consideration the large number of cases of various kinds of infection in the hospitals and intoxication observed and in private practice. Evidently other causes must be at work. and these appear to be in some cases exhaustion and in others a pre-existing neuropathy. not infrequent to meet with an account of cases presenting similar attacks or of cases of manic-depressive or other psychoses in the an- . as these toxic insanities present and other poisons. STUPOR 51 may stand in close relation to various auto-intoxications. CONFUSION. It would appear. that the in confusion as gout now and then met with metabolic affections. the various narcotics. Toxic agents introduced from without Especially is may also play a role. it is a clear family history of insanity. Inasmuch special clinical features they are considered separately. there Indeed. only produce confusion in a small proportion of cases. both of which factors diminish the resistance of the nervous system to the action of toxic agents. as in delirium. our knowledge of this subject does not permit of accurate statements. bears a direct relation to the is toxemia of these disorders. Equally probable it that the confusion occasionally observed in diseases of the viscera. Unfortunately. under given conditions. of the liver and kidneys. for example. however.

names which convey the notion of its two prominent features of hallucinations. as well as the persons about him. its but usually mistakes fail meaning. However. pointed out is less —Confusion when active—as already —approximates dehrium. becomes and confused. —activity patient of symptoms and the presence active form that It is to this we less will first give our attention. and prolonged lactation. the bed. mental and emotional overstrain. physical overexertion. In the course of a few days these symptoms become more pronounced. Symptoms and Course. Uttle by heavy. complains that he cannot think. and other objects. He understands very imperfectly what is said to him. dull. He is. Meynert). and excited. Sometimes he catches a word or phrase. has a fear of forgetful. the patient is The consciousness of is more or less obtunded. fails to recognize his room. but sometimes possible to attract his attention for a brief period by speak- ing plainly and repeatedly to him. is some impending evil or disaster. and. though the excitement affection itself it marked and the much more prolonged. . excessive worry. nervous. The patient begins to lose the correct appreciation of his surroundings. The commonest objects to be recognized.52 cestry. little. He talks becomes of dying. unable to properly collect his thoughts. very much afraid. The onset sleepless is rapid than in delirium. MENTAL DISEASES Among causes of exhaustion we must recognize such factors as the physical depletion attendant upon the various acute infectious diseases. the prick of a hypodermic needle may inspire may be misit taken for an onslaught with a dagger. He does not know where he and often begs to be taken home. a spoon or a thermometer deadly fear. because tions as of its activity has received such designa- "mania hallucinatoria" (Mendel) and "hallucinatorische Verwdrrtheit" (hallucinatory confusion. The is and restless.

to run about the room. The illusions play an even greater role than the hallucinations. As in delirium. visual hallucinations. tortured or destroyed. and these are and distressing. or such a fate is He is about to be in store for others whom he holds dear. or at most betray only a feeble and fragmentary systematization. however. Usually. or to . and sions not surprising that his illu- and hallucinations should in turn give rise to delusions. he may hear shrieks and curses. the hallucinations are quite evident. however. and may even try to get out of bed. rule. though sometimes laughter and singing of exaltation are observed. they are so In marked as to alternate with periods of depression. signs of exaltation are present for brief periods very infrequently do they form a feature of the clinical picture. there usually is some excitement and hurry obscured and often dreamlike. make The CONFUSION. Rarely. the patient is restless. Consciousness The prevailing emotional tone one of depression. the hallucinations appear to be pleasurable. though it is much less in deUrium. and usually for brief periods of time. frequently. in the active form here described. and other evidences As a . They make their appearance early. or. Motor excitement marked than is usually present.GROUP I —DELIRIUM. consciousness becomes may no longer be possible to arouse train of thought is is the attention of the patient. However. so that it established. and. the auditory hallucinations greatly predominate. The dis- ordered and confused. as in delirium. rare instances. however. by their prominence obscure the presence of the hallucinations. may have terrifying On the whole. STUPOR 53 Hallucinations also painful their appearance. is of thought. These are unsystematized in character. while. more rarely. patient sees frightful objects and it is hears threatening voices. As the confusion becomes more obscured.

gradual. The pulse is slow. and the confusion disturbed. partly as a result of fear and suspicion. symptoms reach their full development The subsequent course is in about ten days or two weeks. Convalescence as a rule. partly from loss of appetite. However. normal takes Little place. the now and then. of very evident. is The speech markedly Sleep is of the patient more or less incoherent. In some cases. The nutrition falls or and there is loss of The patient may if may not be indifferent to the is bladder and bowels. bathing. be exaggerated. especially is is this the excitement marked. This statement likewise applies to the symptom known as automatism. there is motor quiet. by little the patient. subnormal.54 MENTAL DISEASES Occasionally. is Food administered with difficulty. the confusion being at times less and at times more pronounced. weight. always more or less irregular. and months. and may suggest the fixation met with is in catatonia Part I. becomes appre- ciative of his surroundings. intensity for weeks This condition persists with varying until gradually a return to the is. he may be in- the case The tendon when reflexes may or. instead of restless- escape from his attendants. continent. the temperature normal As a rule. the patient may He perfectly still. Chapter V). the patient may preserve for a time a given attitude in which he happens to be placed by his attendant. The periods of lucidity is become more prolonged until convalescence fully established. and partly because of inability on the part of the patient to recognize the proffered nourishment as food. is this infrequent in cases in which the confusion active. little much The patients sleep but except as the result of medication. . the confusion deep. for periods of time. usually his ideas so. or other measures. he his attitude (see may remain a long time in one position. ness.

but they are not pronounced and no longer form the basis of delusions. such as tuberculosis. Little by little. and he may be a little distrustful and suspicious. or may is even induce more or less prolonged relapses. be borne in mind that at this stage undue strains or emotional excitement may retard convalescence. Mental weakness. sepsis from a bed-sore or other source of infection. There are present marked confusion approximating at times delirium. Gradually they also disappear.GROUP I —DELIRIUM. is During convalescence the patient dissatisfied. CONFUSION. ally. friendly. more in and manifests confidence those about him. STUPOR 55 In the larger number of cases a mild excitation or depression is present during the early subsidence of symptoms. —The diagnosis of the active form illusions is readily made. it At is the same time that these mental changes are observed. however. marked with or without hallucinations. at other times often irritable. . grumbling. at other times and less frequently. still after lucidity has made its appearance. or other viscera. it may occur. more or less marked. marked restlessness or. rather the latter than the former. Exceptionmany months or even a year or more may elapse before a return to health takes place. — Death is very infrequent. of the active The duration of an attack of confusion form approximately from two to four months. and often longer. hallucinations may be evident. in- hibition of movement. notwithstanding. due at times to extreme exhaustion and at others disease of the heart to complications. Diagnosis. full may persist subsequently for some time. also noted that the patient's physical condition It should is improving. he becomes sensible. Prognosis. At times.

is When general causes alone are at work. illusions all. arteriosclerosis. we have to deal with toxicity and exhaustion. of tuberculosis or other debilitating conditions. It is necessarily an affection of variable duration. the prognosis of the underlying affection. —As in the active form offers of confusion. acute dementia. the reader referred to Part II. and hallucinations not at active form. as already stated. the prognosis influenced in to special part by the degree of the exhaustion. Some cases are so slightly is pronounced that merely a mild confusion noted.56 MENTAL DISEASES PASSIVE CONFUSION Confusion does not always present itself. privation and exposure. shock. as has already been pointed out. As before. of of gastro-intestinal disorders. also spoken of as stuporous insanity. is a form closely allied to conis Indeed. When due causes. in contradistinction to active confusion. or of special causes. is. the prognosis other things equal. disease that should always suggest the It may be purely symptomatic of general causes. such as repeated and excessive hemorrhages. such as the exhaustion of overstrain. however. exhaustion As in the and intoxication appear to be is the basic causes. or curable dementia. Concerning this interesting and imis portant subject. in the active form just described. be properly termed passive confusion. STUPOR Simple stupor. the mental sjmaptom-group of itself nothing unfavorable. and both the duration and the degree in which the symptoms are present depend upon the causes at work. mild confusion so often its symptomoccurrence of exhaustion plus visceral latter. only occasionally. Prognosis. its relation to confusion so intimate that it . Mild confusion may. of malignant disease. fusion. Chapter I. atic Indeed.

during which the patient from more or stances cially is less marked confusion. the purposes of served by a separate consideration. Usually there a preliminary period suffers of several weeks' duration. —The etiology is that of delirium and confusion. erysipelas. CONFUSION. Soon mental confusion makes its appearance. in its tjq^ical form. etc. the preliminary stage of confusion lasts but a few days. great mental or physical overstrain. exhausting fevers. shockfright. Again. we have a history of infection and exhaustion.— GROUP I —DELIRIUM. and for practical purposes stupor may be divided into the complete and incomplete forms. or in which is an infection or intoxication grafted on a previously exist- ing exhaustion.. we can only is conjecture. Only in exceptional in- this period short or relatively short. STUPOR 57 may with justice be studied under the head of confusion. Etiology. and why in another they produce stupor. is weak. S3nniptoms and Course. looks ill. of the exanthemata. or fails to recognize the people about him. Rarely. believes himself to be in a strange place. is characterized by an abeyance of the mental faculties. Why in a given case these factors produce con- fusion. Stupor. —Simple stupor does not is make its appearance suddenly. loses his appetite. the intoxications. espe- in cases complicated by profound shock. This abeyance of the faculties may be complete or incomplete. clear cUnical conceptions are best However. is worried and afraid. Early in the attack the patient suffers from insomnia. complains of headache. to the greater or less degree of the resistance offered by the patient and to the intensity of the toxic invasion. The . to be sought in the in- dividual susceptibility e. inability to think. Doubtless the cause i. the puerperium. The patient begins to lose the proper appreciation of his surroundings.

elapses before any change is noted. remained in this condition until the latter part of the following December. the face is relaxed. Sometimes the course is exceedingly prolonged. The or. Often he remains in one position.) The patient is quite helpless. are. not present in a typical degree as in catatonia. As a lie rule. and often a much longer period. Usually the bowels are constipated. and the inabihty to appreciate the surroundings becomes more and more pronounced until he lies motionless in bed. though the rate loss of weight. often soils he is indifferent to the bladder and bowels and the bed. great exhaustion of the nerve-centers. is not much altered. Fixed positions. The little pulse is small and somewhat slow. however. and there may be slight cyanosis or even edema of loss of the extremities. Everything indicates a vasomotor tone. surface of the body may be cool and the extremities indeed. a loss of innervation. depression. expressionless. . will not answer. The time. who became stuporous early in October. The limbs in the positions in lies which they happen to be placed. though at times shght signs of transient emotional disturbances — for example. the body temperature may be subnormal. excitement. placed in a position by the attendant or physician. I. There may be considerable and in women menfor a long struation usually ceases. indifferent to everything about him. patient if quite still. weeping —may be noted. course of simple stupor varies but little Three or four months. flaccid. may re- tain this posture for a time. The respiration is shallow.58 MENTAL DISEASES confusion from which he suffers becomes deeper and deeper. a young woman. as in a patient of the writer. The face is pale or a dusky. The cold. Emotionally he seems placid and indifferent. He will not speak. His surroundings do not make the slightest impression upon him. or automatism. (See Part Chapter V.

for observed under such circumstances. as already outlined in •considering the etiology. somewhat marked in the mornings. example. which are more or is first less intelligible. there a gradual change face. usually there the history of the de- velopment of the symptom-group in the convalescent period of a fever. In stuporous ^vith melancholia there typical depression is always the period of invasion Part I. is As a rule. the improvement less noticed in the evenings. or other factors are present. —The diagnosis of simple stupor is not difficult.GROUP I —DELIRIUM. . and then gradually grows it is more continuous. the (see Chapter IV) and self-blame. We first notice some return of expression in the face. CONFUSION. Simple stupor is to be differentiated from the stupor of melancholia and the stupor of catatonia by the history. Convalescence is gradual. There is present the history of a previous infection or toxic is cause with exhaustion. ical signs are also The physis those of improvement. and an obvious gain Diagnosis. I. noticed that the patient becomes of confusion are and frequently recurrences as. Chapter V. when the patient attempts a rather prolonged conversation. in the general nutrition There is also an improvement in weight. STUPOR for a period of 59 when she became relatively normal about two weeks. During convalescence readily fatigued. for the better in the circulation. perhaps attempts at speaking or gestures. stupor there again a definite history of a special symptom(See Part group preceding the development of the stupor. fixation. is while the stuporous condition in every now and then broken In catatonic upon by periods is of melancholic agitation.) The stupor itself presents rigidity. and in part by the symptoms. when stupor again supervened and persisted until the latter part of the following August. in the color of the sur- and in the temperature of the extremities.

though slight. indeed. this not the invariable In a small number of cases. result. INCOMPLETE STUPOR Incomplete stupor. and there are present from time to time automatic movements. and may even assume the form of a terminal dementia. a permanent. Sometimes also visceral complications fatal result. The case may at first resemble a delirium of exhaustion or a confusional insanity. Hallu- . really a stuporous confusion. other things equal. The patient is soon unable to understand the simplest questions. and at an early stage loses all touch with his surroundings. make and determine a though this also is rare. and constitutes. but in a short time the confusion becomes very deep. This is true of the great majority of is Usually also the recovery complete. Such a result. consciousness soon becomes deeply obscured. or stupor with excitement. mental weakness persists for many months. and. mental Rarely this mental imimpairment may be established. It begins with sleeplessness. a transition be- tween ordinary active confusion and complete stupor. while hallucinations are more or less evident. ordinary stupor in the fact that the stupor less absolute. differs from is less profound. mental integrity is being fully restored. is very exceptional. and it is probable that in such cases complicating we really have to do with a (See Chapter V. —As is in ordinary confusion. great irritabiUty. stereotypy.60 MENTAL DISEASES automatism to a marked degree. and that symptoms added to the of confusion and physical It is restlessness are clinical picture. however.) their appearance stupor a dementia prsecox. the prognosis cases. disconnected and excited speech. Prognosis. pairment is pronounced. in fact. As in ordinary stupor. good. Unhappily. At times a tuberculous infection becomes apparent. verbigeration. and physical restlessness.

GROUP I —DELIRIUM. makes purposeless movements. and prognosis of incomplete stupor do differ materially from those of ordinary stupor. may also be The not course. CONFUSION. As in complete stupor. or may for short periods assume fixed positions. four. facts more —there is a gradual re- turn of an appreciation of the surroundings and generally a recovery. for the surroundings are not interpreted at all. or After the lapse of months —three. though now and then the signs some emotional disturbance are noted. resists. The already stated in regard to ordinary stupor apply equally here. . and a marked feature. duration. the face of is expressionless. The patient is restless. The general physical signs in and general bodily conditions are those observed stupor and need not be rehearsed. perhaps clings to surrounding objects. the administra- because of the motor excitement. no longer formed. tugs at his bed-clothes. STUPOR Illusions are 61 cinations cease to be manifested. tion of food sleeplessness is difficult simple As a rule.

— in individuals of mobile and temperamental i. mania.. is probably much larger — present a history of- melancholia-mania or other forms of insanity or neuropathy in the ancestry. forms of mental disease in which the individual attacks are characterized. clinical entity. readily depressed be. MANLA. Both phases. as will apparent present the special features of an inherent fact. by the following features: an emotional state.-MANIA. The widely become differing pictures of melancholia and mania are but expressions of one and the same later. the truth were known.— CHAPTER IV IN- GROUP II—MELANCHOLIA. 30). that persons who happen to possess the last-mentioned qualities if are necessarily neuropathic or abnormal. the larger number if estimated by Kraepelin at 80 per cent. in general terms. In keeping with this be noted that of cases heredity plays an important role. given to poetic or artistic or excited. as also pointed out is chapter on Classification. it may and day-dreams. first. in the Again. This does not imply. maximal intensity. a wave-like course of gradual in- crease. it is to neuropathy. in persons who are emotional.. and which. e. or ideas who are. of course. for 62 this were the . melancholia. apt to occur —though by no means always extremes. and circular insanity. CIRCULAR SIVE INSANITY) As already pointed out in SANITY (MELANCHOLLA. second. either of depression or of expansion^ clinical which dominates the entire all picture and outweighs other symptoms. and final subsidence. MANIC-DEPRES- the chapter on Classification (p. we have in Group II. melancholia-mania.

tific. about in the proportion of 2 to 1. occur much later and. but may life. That persons who are the victims an inherited neumanifest their all. of between eighteen and thirty years of course. or scien- but which frequently come to naught because of inherent weakness. life. It is. e. e. Melancholia-mania occurs most frequently in youth and early adult ing. is that melancholia-mania occurs more frequently in females than in males. it occurs with especial frequency. CIRCULAR INSANITY 6S some of the world's greatest achievements in Uteratm-e. The individual of normal constitution passes through this period unimpaired. and enters either upon a depressive or expansive wave. attendant perturbations.. ropathy —a manic-depressive insanity —should is. and strain. literary. . An interesting fact to be mentioned. MANIA. i. feelings of The immature with their youth give place to serious love affairs. cess. impracticability. artistic. II —MELANCHOLIA. as just stated. very rarely. earlier. quite a usual experience to meet with persons i. or some other essential defect. adult life is one during which the transition from youth to is takes place. and science would have to be looked upon as pathologic. and happiness. we should remember. who make attempts. or perhaps passes through a succession of both. To-day may be with the promise of suc- but to-morrow may bring the reahzation of disappointof ment. to emotional stress. about the third decade.. affliction especially at this period of life after not sur- prising. sion. art. and peculiarly subject to emotional upheavals.GROUP case. more broadly speakage. in the third decade of This period. the day-dreams of the boy to the It is ambitions and aspirations of the man. or. However. It is not. of the temperament here outlined. limited to this period. an age of expan- pleasure. but he who is the victim of the manic- depressive neuropathy breaks down. the manic-depressive temperament. however. but also of depression and of filled suffering.

and circular insanity constitute closely related forms of one clinical entity. a wave-like course. or confusion with depression from melancholia on the other. and circular insanity bear no relation Unfortunateh^. is other things equal. seems necessary to add that melancholia. mania. The facts upon which this conclusion depends had best be enumerated after the various forms have been studied. to infection. however. In the vast majority of cases. an abnormal inhibition of the mental and physical . and pursuing. stated. Finally. come on without any antecedent cause to which the attack could be ascribed. by Kraepelin. and on the whole. expect in there has been nothing This is is what we would. to in mania. or to visceral disease. of course. on the one hand. it must be constantly borne in mind that." introduced is. to be preferred to the more "melancholia-mania. such factors are altogether absent. a depressed and more or less persistent. The usual history is that the attack of melancholia or of mania has . sive The term "manic-depreslargely insanity. is still trauma.64 ' MENTAL DISEASES it is Exciting causes are of doubtful value. though believed that profound and sudden grief or other emotional overstrain may in some cases determine an onset. an affection which It hardly essentially neuro- pathic and hereditary. There also present activities. the writer not having taken the care to differentiate mere states of delirium with excitement from mania. text-books upon internal medicine the statement occasionally made that melancholia or mania occur as sequelse of this or that form of fever or infection. as already melancholia." awkward expression MELANCHOLIA Melancholia may be defined as a form of insanity in which is the essential and characteristic feature painful emotional state. has been accepted.

to make a position many alienists. — The facts of heredity need not again be rehearsed. however. Pro- found grief or violent role. reserved. as we It is number of forms. brief separate conII. the onset exceedingly slow. at times seems to be sudden. CIRCULAR INSANITY 65 Etiology. Again. whom the melancholia has appeared without of significance. clinical entity. following the lead of form of melancholia a separate justify. are However. part of of this There has been a tendency on the Kraepehn. ages. like mania. it would appear. a II. repressed. pre- any antecedent circumstances Symptoms and Course. elapse before the affection is estab- Occasionally. The prodromal period varies somewhat in different is cases. the onset it relatively rapid. sents itself in a —Melancholia. GROUP II Suffice it to say that they apply. third. however. the period of full development. the prodromal period or period of evolution. Melancholia is apt to occur in persons of a timid. while melancholia. occurs life. Statements as to . Similar remarks apply also to the ques- tion of individual predisposition. it by preference in the third decade of also occurs at other life. is Weeks and months may lished. second. is Notably is it met with at the middle period of and then often spoken of as the melancholia of middle age or the melancholia of involution. the simple acute form which will first claim our attention. and. shall see. accorded it in Part Chapter is known of exciting causes in melancholia. and introspective temperament. the period of subsidence. patients met with continually and in in whom no such factors have been present.— MELANCHOLIA. emotions have at various times been supsimilar is it posed to play a with excessive fatigue and long continued depressing surroundings. with especial force to melancholia. MANIA. indeed. which the facts do not sideration Little is However. Here the course of an attack can be conveniently divided into three periods: first. In the larger number.

easily depressed. emotionally easily dis- turbed. does not sleep well. may be about business happenings. but both the fact and question. . He may complain of tinnitus. indeed. family affairs. are often due to faulty observation. not severe. He diffuse. becomes fixed finally and unchangeable. There gastro-intestinal atony. its significance are open to In the ordinary acute form patient is it is usually observed that the nervous. falls. the vascular tension though the pulse-rate may not be much The affected. The patient loses his color. nant feature of the . There is a general malaise. and later — and Up to this is of great significance this — about is his past conduct. The nutrition is impaired. it time the patient's mind entirely clear. Gradually the symptoms become accentuated the depression until it becomes gradually more and more pronounced. patient suffers from headache The —vague. and then constitutes the domicase. perhaps a gastric catarrh. constipation. about his health.66 the latter MENTAL DISEASES mode of onset. The is appetite is diminished. A more frequently ascribed to cases of hypo- melancholia. a sense of weakness. Gradually the tendency to worry patient at it becomes more pronounced. is does not occur to friend or relative that the patient suffering from anything . an inability for exertion —a more or less marked loss of energy. the patient not having attracted the attention of his friends or of those about him until the symp- toms had already attained a certain degree sudden onset is of severity. I am convinced. disturbed sleep or insomnia sooner or later become features of the case. first is apt to worry in regard to miscellaneous matters. but a mild indisposition without much importance is it least of all suspected that he is developing a serious mental disease. a coated tongue. occasionally attacks of palpitation are noted. however. and inclined to worry.

that his speech hesitating. without saying. there is also an in- hibition of cerebral activity. or. comes very marked. the arms hanging. is are sad or are suffering from sorrow or from but in others. When spoken to or perhaps brusquely If he does speak.GROUP II — MELANCHOLIA. Doubtless it was some such thought as this that prompted Clouston to term this condition "psychalgia. that his thoughts are retarded. his manner abstracted. as though by sorrow." The attitude. He then talks very the speech is slow. in intensity. of the hopelessness of the future. the whole attitude one of ness and dejection. picture presented it is that of psychic pain. features drawn and distorted. and the words uttered are all indicative of mental pain its and suffering. of his moral worthlessness. CIRCULAR INSANITY 67 In the fully developed period the term ''mental depression" is wholly inadequate. The head the shoulders listless- drooping. and appears to be is in the in the psychic world of feelings what trigeminal neuralgia physical. hopelessness. The MANIA. We note that he speaks slowly. the pain more intense. psychic suffering. disturbed he may weep. often limited to a few words and short phrases. The patient is quiet. That it is a "pain" that is different is from others that human beings are capable It of feeling extremely probable. In some cases this symptom belittle. is despair. evidently wishes to be let alone. quently he will not talk. would seem that in some patients the experienced suffering corresponds to the painful emotions when normal persons grief. that he will tell of the sin he has committed. it may be. in addition to his physical inhibition. we may find that is his voice is low. that. The bowed. the expression. sits still. remains Fre- apart and by himself. in different cases goes That varies in degree. face is pale and grief. and even these are uttered as though the patient unloaded them with an . and unhappily in the larger number.

that cannot be delusion relates to of atoned tirely for. patient constantly reproaches himself." Some often trivial and inconsequential. is hopelessly that he cannot be saved. it is always a punishment which he has brought upon himself. poisoned. or that he to be executed for some crime. a man unimpeachable character. as already hinted. a crime that cannot be undone. Most frequently the some en- imaginary experience. has ruined and disgraced his family. that his soul lost. of the known technically as the "delusion act of the patient's past. The patient believes that he in a state of moral worthlessness. eviscerated. is also the fact that eases of melan- choHa write very few Added to the cardinal symptom of psychic pain there are. sentenced to death. It is always himself who ills is to blame. MENTAL DISEASES In keeping with this letters. delusions. He alone is author of the terrible situation in which he finds himself. It is always himself who has wrought the from which he suffers.68 effort. his soul is lost. that he has been hopelessly wicked. has hopelessly offended God. he can never be forgiven. who the has caused misfortune and pain to others. may be taken up and con- strued as a sin. unpardonable sin. tortured. The delusions of melancholia are always characterized by the fact that the patient invariably refers the cause of his suffering to himself. a punishment which is being inflicted upon him justly and which is the result of . sometimes believes that he is in prison. is Even being when he believes that he is being punished by others. These delusions are unsystematized of a painful is and are always and of a depressive nature. The He has brought misery and suffering upon others. Thus a woman unimpeachable virtue of may believe that she has sacrificed her chastity. endless pain and punishment lie before him. is He is fearful and timid. moral ruin. There arises in the great ma- jority of cases a delusion. or feebly systematized.

indeed. that they constituted a severe strain upon her nurses. as we will see. visions. and always with the same conviction of truth and reality. a woman. of his sins. would "If I for hours repeat in inexpressible anguish the phrases had only said 'no!' said 'no!' said 'no!' " So great and long continued. he has simply been wicked.GROUP his II —MELANCHOLIA. death's heads. in the latter. At such times the . though of sight may also be present. The and MANIA. the patient always seeks for the explanation of his suffering world. hallucinations are also prominent. sees phantoms. hopelessly wicked. but will merely and moan. he does not require a doctor. in the outside As has already been stated. the patient talks very It is little. the form which we are here considering. children —whose suffering he has brought about. In the acute form. CIRCULAR INSANITY 69 own acts. and then only about his terrible plight. massacres. most important point in the differentiation of melancholia from the depressive phases of the paranoid states. Sometimes the pa- hears the cries and shrieks of others —men. always this constitutes a self-accusatory. suffering. tient told of his crimes. so distressing were these lamentations. the At others monotonous same phrase expression as did one of my patients. sometimes he gives vent to he or will repeat. The patient suffers from horrible of suffering. Quite commonly they consist of hallucinations cries. women. tient cannot be At times the pasit made to talk at all. of The patient hears is voices. who She suffered from the delusion of violation of chastity. scenes people being burned alive. delusions are never truly persecutory. they are very fre- quent. less frequently. in tones of cries and lamentations. and words of reproach. hearing. hallucinations In pronounced cases. the delusive tale told again its and again. He is not sick. the constantly reis curring story of his self-blame. blood. curses.

Almost always present a severe and sometimes obstinate constipation. to his personal appearance. consists of urine and feces. be mentioned and delusions are concerning himand friends. putrescent. to the surface. relatives he is apathetic or indifferent. sometimes he shows aversion. some cases. indeed. the tongue is white and pasty. They are always distressing and painful in nature. scanty and thick. decomposing. and there marked Often there there is is present an acid indigestion. Rarely does he manifest anxiety in regard to others. the flesh of corpses. is now a marked The and mouth are dry. Visceral hallucinations and general or local somatic hallu- cinations referred to this or that part of the body. His indifference extends also to his surroundings. The patient may . and doub.tless enter into beliefs of torture. as regards others. The food tastes horribly. initial Second. and then usually only when the latter are in some way entangled in his delusions. and to his dress. illusions of taste it is and smell are present. and consist of bad odors and gusting tastes. the patient's distress self. suffering. lips pronounced There is loss of nervous tone. the saliva fetor of the breath. to this or that organ. Hallucinations of taste and smell can also be recognized as existing in ing. Every symptom points to a tion. to a defective innervagastro-intestinal atony.: 70 visual MENTAL DISEASES and auditory hallucinations seem to be associated and combined. Very frequently. The loss of appetite is now very profound. and punish- ment. are present in varying degree in different cases. the visceral signs of the fully stage become in the developed period accentuated. A few additional facts as to the condition of patients in the fully developed period of melancholia deserve to First. As in hallucinations of sight and heardis- they are always painful. also.

it is The a little pulse-rate not much changed. is respiration. more particularly pass into the stuporous form. is lessened. in this true in cases which The blood shows some. under circumstances to be considered is increased. CIRCULAR INSANITY This 71 experience a veritable disgust or fear of food. it its specific gravity It also frequently increased. initial The loss of weight noted in the period is more promenstruceases. the alkaline phosphates diminished. later. diminution the erythrocytes and also in the percentage of hemoglobin. is may be distinctly subnormal. The output of The skin is nitrogen. is abnormally dry and the hair The per- spiration usually much diminished. more especially the surface temperature. brittle. and quite commonly . the extremities are cold. is symptom frequently spoken of as sitiophobia. The proportion of phosphates varies somewhat. is surface of the body pale. it is Sometimes he enterto eat or that tains the delusion that wicked for him God force has forbidden him to eat. though not marked. some- what slower and somewhat shallower than normal.GROUP II —MELANCHOLIA. The temperature. In women ation becomes scanty. with certain exceptions to be noted. it at other times. nounced in the fully developed period. MANIA. though may be diminished. as one would almost expect. urine is usually lessened in amount. is The of the beat of the heart lessened. the earthy phosphates are increased. the electric is resistance of the latter increased. quite frequently slower than normal. D'Abundo The The is believes that its bactericidal activity is lessened. even slight is puffiness or edema may be noted. The The circulatory apparatus also reveals changes. the arterial tension lowered. irregular. and their distal parts are often dusky or cyanosed. Owing doubtless to the lessened amount of fluid in the tissues of the skin. appears to have a higher coefficient of toxicity than normally.

The cutaneous sen- appears to be lessened. Every can cite such The methods which patients adopt depend somewhat upon the individual case. yet. in reply to questions. he dreads the supervision and possible restraint which the admission might entail. may be due to the mental The same appUes no physical is also to the special senses. Sexually the patient indifferent. may answer that he has never thought of killing Quite commonly when he the patient is makes this state- ment I am convinced that attempting a deception. it may be denied by the patient. the opportunities presented. More dangerous to the successful con- duct of such a case is the fact that relatives. At times it is but slightly marked. or interferes with such measures after they have been instituted. he himself. though this state. the patient physically weak. with fatal consequences. wife. the nature of the delusions. a mother withdrew her daughter from an asylum .72 MENTAL DISEASES From the strictly neurologic point of view the patient pre- sents but few is symptoms. A wife withdrew her husband from the watchful care of an attendant and en- couraged him to resume his business. The save during periods of ex- citement. often a mother. indeed. The muscles reflexes. The latter may say that life no longer holds any- thing for him. death by pistol wound on third day. reveal no changes of sibility moment. The sphincters are normal. lack tone. or sister. that he might as well be dead. a point that cannot be too strongly insisted upon. They reveal signs. death on seventh day alienist from gunshot wound of head. experiences. This present in practically every case. An cholia all-important fact to bear in is mind is in regard to melan- the tendency to suicide. flouts the idea of suicide and prevents the insti- tution of protective measures until too late. and whether or not the patient is under super- . Thus.

inhalation of chloroform. especially is this the case if the as method in requires strength. Because of the loss of appetite and. would occasionally be successful. or childish. the leap from the pistol shot window. strangulation. as failed to prick her in the case of a patient who with her hat pin. hanging. star- but for intervention. self-strangulation. and which. from a window. 73 the gas. but with insufficient force to do any harm. absurd. Patients quite frequently lack the decision and determination to carry out the suicide which they have planned. and scissors. And yet patients who now and temporal artery then fail with one method are often successful with another. continuous effort is is A method vation. knives. CIRCULAR INSANITY that supervision. the chewing and swallowing of paper. and the character Among methods adopted are asphyxiation with illuminating swallowing laudanum or other poison. It is the sudden leap into the water. drowning. but subsequently shot herself through the heart. wounds with cutting Sometimes the patient adopts some particularly horrible method. cutting the throat with a razor. death by firearms. being ill-advisedly re- moved from at her the asylum by her relatives. or sustained effort. would appear that such methods are in keeping with or suggested by the punitive character of the delusions which these patients frequently entertain. leaping from a height or head foremost glass. swallowing broken instruments. as. Sometimes the attempts at suicide are wholly inadequate and the methods trivial. for instance. or the tying of a handkerchief or cord around the neck. indeed. burned herself to death It own home. actual disgust for food so markedly present in the average case. trying to open an artery with a pin. force of will. the ary rather than the —the act that requires but the moment—that so often chosen. of MANIA. as in the case of a woman who. that patients often persist in for a time.GROUP vision II —MELANCHOLIA. the .

complains of his terrible plight. The at times pre- ceded by a premonitory restlessness. moans and for cries out.— 74 patient often MENTAL DISEASES abstains from food spontaneously. The picture is often one of marked mental and physical met with inhibition. and. sometimes quite rapid." In some cases of melancholia. is Every in now and then. and is then commonly spoken of as ''melan- cholia agitata. the patient moves but upon the that he tends to remain quiet for long periods of time. the patient is restless and anxious. condition terrified intense. MELANCHOLIA WITH AGITATION The picture of melancholia thus far outlined Stress has been laid little. still. and that his thoughts are retarded. ever. After the fully developed period has lasted for a time . struggle with his attendants. kill attempt desperately to himself. that his speech is slow. if the sitiophobia appears to be associated with the delusion already mentioned that it is wrong for him to eat. it is present during a large. patient moans. a major portion. However. may tear his clothing." is less At other times the agitation and disturbed. agitation never in others supervenes. The may persist some time. he may it readily drift requires into starvation as a effort means of self-destruction. no on his part. in others. is that of the fact that ordinary acute form. wrings his hands. the "melancholic frenzy" or "raptus melancholicus. the attack does not always present itself in this form. shrieks. or even during the entire attack. merely a passive acquiescence. the quiet phase The transition from the agitated to it is may be gradual. it appears as a more frequently. agitation occurs in episodes. a case is in which the quiet agitation is broken upon by periods of agitation. At times the attack so-called amounts to a veritable frenzy. often in the same position. howDuring the attack the sudden outbreak.

he begins to take more food. offer a less hopeful Diagnosis. The duration i. the evident reference of the suffering of the patient to himself. leave no doubt as to the nature of his affection. of the unpardonable sin. and seeks their explanation in persecution and conspiracies. a first attack- — is about four months. the self-accusatory attitude of mind. not The history of a gradually oncoming and deepening depression. variable tion. neurasthenia (see Part for symptom group I. is The course of an attack of melancholia is by no means always uniform. He again becomes cheerful. a gradual subsidence of symptoms. to gain in weight. there not always the history of a gradual increase. and rule.. a maximum and is Some- times the course in such cases is intermittent and irregular. cases with an irregular course outlook as regards the individual attack. Usually the memory of the attack more or less clouded for the period of the maximum intensity of symptoms. of an attack of simple acute melancholia e. a normal As a the symptoms subis side gradually. several months — the II MANIA. his delusions become less insistent. and less mistaking it for paranoia. the delusions of self-blame. and not infrequently it is much more. his His depression gradually grows hallucinations disappear. CIRCULAR INSANITY 75 patient begins gradually to imless. Little excuse can ])e given for conof the fatigue still founding such a case with the neurosis. Chapter VI). In the latter affection the patient refers his sufferings to the external world. is and little by little convalescence finally reaches established. Prognosis. but subject to sudden lessenings alike in intensity and sudden exacerbations. diagnosis of melancholia is. — MELANCHOLIA. The depression not uniform. very Rarely is it less. —The prognosis is favorable as regards the indi- . level.— GROUP usually prove. —The as a rule. and dura- As might be expected. difficult. to sleep better.

however. again. noted in ordinary melan- cholia. close relations to mania. bears. too. from exhaustion every now and then occurs. considered as a whole at the HYPOMELANCHOLIA Melancholia does not always present outlined. it is met with in a subacute form. is The prog- nosis of the latter affection close of the present chapter. lacks energy and initiative. There is again a painful emotional state. itself in the form here Every now and then. is though these infrequent. essentially Unfortunately melancholia recurrent. At first he forces himself by sheer effort of will to do his daily work. to perform the sim- plest duties. it pursues a distinctly milder course. more and more and finally fails utterly to meet them. It it is a form which can properly be termed "hypomelancholia. and may even at times approximate the depression of ordinary Sometimes. Soon he puts off his engagements. indeed. On the whole. in individual cases. episodes occur in which the melancholia. long continued. becomes gations. defers answerindifferent to his obli- ing his letters. an affection which and which is. is also a marked feature here. and affection. Sometimes it consists merely of a simple proit is longed wave of depression. though this hardly accords with the experience of the writer. depression is much accentuated. The patient is inactive. Its degree varies in different cases and often at different times in the same case. indeed. visceral compHcations arise. He avoids . but which falls below that of typical acute melancholia in intensity. often but one phase of a larger circular or manic-depressive insanity." then presents the following peculiarities said to be : In mode of onset more rapid and. at others more marked. at times sudden. The physical and psychic inhibition. indeed. are is vidual attack in the large majority of cases.76 MENTAL DISEASES However. death Sometimes.

but here again the acts of his friends and neighbors. and doubtSometimes serve is as hy]3ochondriac ideas. In the experience of the writer hypomelancholia occurs more frequently among men than among women. The duration The of hypomelancholia of the as a rule. the same. Though the psychic suffering is not as acute as in ordinary is melancholia the attitude of mind worries. recover from . At others still. II —MELANCHOLIA. hypochondriac in character hopelessly ill. or typical desin lusions of the unpardonable may develop. a year and a half. as before. and then. finds fault with himself 'jecause of things he has done or because of things that he has failed to do. can be safely hazarded that the patient a year. delusions are present they are somatic e. MANIA. Hallucinations of hearing and of the other special senses are very infrequent. —the patient believes that he is has this or that incurable visceral or constitu- tional disease. CIRCULAR INSANITY 77 occupation. are the result of his own conduct and he himself is to blame. However. is.— GROUP effort. society. remains at home. dura- and its difficult of prognostica- However. somatic hallucinations. His ideas may when acquire all the force of delusions. his ideas are religious. Sometimes.. very prolonged. perhaps in bed. however. though much the ideas are per- secutory. but extends over a relatively longer period will see. will after many months. the various things that are being done to him. it of time. self-blame and hopelessness play the less frequently. Very frequently. —but one phase of a larger outcome are matters most it cycle. illness. At other times. as we forms —as may ordinary Both its melancholia tion tion. vague and less ill-defined. The patient blames himself. it altitude wave is less. i. essential role. cannot exert his will to meet the ordinary routine of his daily living. appear to be present in a basis for many cases. incapable of effort. there a general feeling of bodily a general cenesthetic hallucination.

The danger is the greater because the true nature of the affection recognized. and like disorders. of their thoughts. an attack which may otherwise resemble a typical attack of acute melancholia. he relatively so clear. not always Patients suffering from hypomelancholia every are mistaken for cases of nervous prostration. nervous dyspepsia. neurasthenia. or. not surprising.— 78 his attack. now and then Finally. The term "constitutional emotional depression" adequately describes their condition. MELANCHOLIA WITHOUT DELUSIONS Melancholia occasionally presents itself in a third form i. usually. e. impracticable—to surround him with adequate protection. some patients appear to be in a condition of melanAll cholic depression throughout the greater part of their lives. as a rule. is my is experience this danger decided. in a sense. sometimes. Commitment can only The It is rarely be The relatives and friends. is The patient's lu- cidity it is frequently so pronounced. patient himself rejects the proffered nurse or attendant. indeed. advised. and their cases may its be looked upon. he commits the act in is an impulse bred of an accession of symptoms. too. The danger In of suicide in hypomelancholia deserves a word.. . scout the idea of confinement in an asylum. of hypomelancholia. and. neither hallucinations nor illusions. as representing the underlying neuropathy of which the frank melancholic attack with wave-like course is the more complete expression. fore. acts and experiences are accompanied by feelings that are distressing or painful. that often impossible— indeed. MENTAL DISEASES but whether the attack will be followed by a period of lucidity or will suffer transition into a phase of ex- pansion cannot be foretold. therekills that under these circumstances he not infrequently himself. it may be. is distin- guished by the fact that there are present no delusions nor any special sense disturbances.

namely.. there is This psychic suffering it is may may be relatively mild. no delusions of sin. e.. fact of the lucidity of the patient somewhat enhanced by the and the consequent course. of the attack usually many months. not move. the duration very prolonged. but one symptom. Not moans infrequently such patients become fro. in addinutrition. but more frequently attain the degree of severe intense and agony or of exquisite anguish. the patient with melanless from a more or marked inhibition. melancholia sine delirio. Such patients suggest no condition i. not talk. There is present. as in hypomelancholia. will both physical and psychic. In the experience of the writer. agitated and sit for hours rocking to and giving vent to constantly repeated or other sounds indicative of the great distress from which they suffer. intensity.— GROUP II — —MELANCHOLIA. in cases in tient difficulty of exercising supervision. . that of mental pain present a psychalgia and nothing more. As in other forms of melancholia. mind is MANIA. no explanations as to their there are no ideas of self-blame. or lucid melancholia. merely a persistent suffering. there is is a danger of suicide. maximum years. CIRCULAR INSANITY 79 The patient's entirely clear. the unpardonable no delusions of bodily illness. ideas. is and gradual subsidence. This danger. sometimes MELANCHOLIA WITH STUPOR As has already been pointed cholia suffers out. while the course of lucid melancholia is that of a gradual increase. e. as though spell-bound. In some cases this inhibition becomes so prosits in his nounced that he chair or crouches in a corner mute and motionless. The attack begins. tion to the physical signs of exhaustion and depressed i. is Of which the suffering so great that the pa- becomes agitated and noisy the friends more readily consent to commitment or to other forms of protection. will He sits quietly by himself. Such cases are spoken of as cases of melancholia without delusions.

Every now and then. but the quiet and lessness gradually deepen until finally the patient is inert. no truly cataleptic. and Some- times the phases of agitation are very fitful slight. contracted. he sleeps but little. pulse slow and small. at any rate. The from patient cannot or. phases of agitation are all. The tongue stinate. there is is not or has not trifle The temperature sometimes a sub- the features and body surface are pale. constipation ob- Cutaneous sensibility is very much diminished. does not speak. which under ordinary cumstances readily induces fatigue. coated. cries out. his breast. may be main- There are. like an ordinary melancholia. is restless. the position tained for a long time. though now and then a few. normal. perhaps an cir- awkward or uncomfortable one. no catatonic. expressive of pupils are dilated or usually so. the eyes are closed or the lids are drooping. consist in and transient changes in expression. sitiophobia very marked. not observed at . and may be found at night half-seated in bed or in indicates that he is is some other position which been sleeping. may be punitive as As in other forms of melancholia. is the respirations diminished. suffering. symptoms present.80 MENTAL DISEASES list- as a rule. that is is is the mental reaction to tactile and painful stimulation diminished. which well as painful. the quiet of the patient broken in upon by an attack of agitation. is. during which he more or less disturbed. immobile. the patient assumes spontaneously most uncomfortable attitudes. Very often. movements. however. If he be placed in a position. words issue his mouth. and moans. or whisperings. usually incomprehensible. indeed. or he He may may lie sit in a chair with his chin buried in motionless in bed. a moderate degree sometimes the of lividity of the extremities. and apparently indifferent or oblivious to what goes on about him. probably as a result of his delusions. The The features are drawn. In some cases. again.

but also the symptoms present.GROUP II —MELANCHOLIA. g. The great majority of cases recover from the is individual attack. instead of there being is a general mental inhibition and slowing of thought. there here in an exaltation of the mental the flow of ideas. MANIA Mania may be essential state. is MANIA. may speak of his delusions of in this self-blame. along with inhibition. though the prognosis not as good as in the ordinary form. also of the other symptoms. too. way furnish additional evidence of the nature of the attack through which he has passed. an abnormal rapidity Similarly. CIRCULAR INSANITY 81 This form of melancholia spoken of as melancholia with It stupor or melancholia attonita. In both of the not only the history of the case. words. Sometimes. though sometimes rule. the patient painful feelings may and speak of his and suffering. other things equal. During the period of subsidence. is. expansion there a general release of . as we will see. there is faculties. The duration as a prolonged. of his unworthiness. of that Not only the emotional state the reverse which we observe in melancholia. of his sins. In other in mania physical tihe and is activity. enable a ready differentiation to be made. but this is true. e. melancholia with it stupor subsides gradually.. must not be confounded with the stuporous states which are related to confusion and delirium or which are observed in catatonia. at other times. latter instances. does so rapidly. As a rule. is a wave-like course. an expansive emotional more or and pursuing. instead of physical quiet restlessness and torpor. defined as a form of insanity in which the is and characteristic feature less persistent. the exhaustion is so profound as to threaten death. there are severe diarrheas.

applies also. Suffice it to say. the period of full development. histories overstrain. In first. mania. Again. mania may. history of this antecedent period is Very frequently no obtained. third. However. much later. a few w^eeks. whole. so to speak. that persons That which applies to manic-depressive insanity. Sjrmptomatology and Course. at the early period of life. An attack of pain. or perhaps only a few hours. and that they occur with rapidly diminishing life frequency as middle age and the later periods of proached. are ap- As in melancholia.. is It quite common to speak of the attack as beginning with an exaltation or expansion which gradually or rapidly increases in intensity. in is some cases. great ex- are much more frequently absent in the clinical than present. as a whole. very short. to badly i. as a rule. MENTAL DISEASES — Little need here be repeated as to etiology. a few days. have feeble resistance to alcohol. the period of subsidence. sudden shocks.— 82 Etiology. the simple acute form first —As in the case of melancholia. of course. e. in the third put it in ordinary phraseology. like manner its course can be divided into three periods: the prodromal period or period of evolution. and perhaps for the reason that the patient has not been under observation. exciting causes are of doubtful value. claims our attention. while occurring by preference occur decade of life. an . observed in which the patient de- This period is. too readily — to stimulants. Mental and emotional citement. Clinical experience. on the like melancholia. second." also observed that they react or. to who are especially disposed to manic waves are thought to have "exIt is citable temperaments. Under average conditions to an individual sents little attention is paid by relatives member of the family unless the latter pre- marked or striking symptoms. a period antecedent to is the onset of expansion pressed. shows that the attacks are massed.

The vague and discomfort give way to a sense of well-being. He cannot cannot complains of headache.GROUP II —MELANCHOLIA. irritable. in frank have not been called full until manic symptoms were and Sometimes a history that the patient was not well before the onset of the excitement can be obtained from the mother or other close or intimate relative or friend. These symptoms subside by those of rapidly. or of other excitement.. g. CIRCULAR INSANITY 83 attack of fever. MANIA. of delirium. however. antecedent symptoms must have long been present. and the patient now enters into an expansive state. sleep. would appear. there is nothing inherently improbable in stantly occur in this. that the preceding depression this reason is not improbable for sometimes very mild and not observed. in which affection we know that. most frequently. it has been my fortune to be I summoned during development. of depression is assume that in mania an antecedent period more often present than actual observation would Personally indicate. thus It is forming a phase of the cycle. worried. and perhaps of other has indigestion. constipation. will at once attract attention. at other times the inquiry proves futile. my feeling this is is that such a period always exists. e. though perhaps going too far. . but the vague this and ill-defined symptoms of antecedent period are of such a character as may readily escape notice. therefore. and sometimes also very short. and are replaced sensations of depression mania. are the is symptoms of this antecedent period? The depressed. However. to It is a justifiable position. nervous. What patient eat. circular insanity. left in We are frequently the dark as to the detailed personal history of patients attract attention until they who do not act. Cases of mania con- which the attack frankly follows a well- marked and typical wave of melancholia. despite the frequent paucity of evidence. On a few occasions this period. commit some overt in paranoia. it distressing sensations.

I have for many years believed that the manic state could not be first. he now restless and excited. also. and well be- haved may commit venereal and alcoholic excesses. a psychalgia. Emotionally and intellectually he seems as though exalted. been stated that the symptoms of mania are the it opposite of those observed in melancholia. phasis. intelligible. too. of symptoms. The state of mind in mania must first be considered in order that the detailed appreciated. this does not dition is mean that this opposite conis joy. broken and un- Soon the symptoms become more and more pro- nounced. with em- added that the underlying states upon which these are exactly opposite to each other. a natural one. there is To repeat a cardinal in melancholia a depression. and he appear brilliant may even At this when compared is to his ordinary self. and the patient enters into the fully developed period of his attack. happiness. also. filled with exclamation marks and numerlike ous underscorings. but this hardly leads to adequate conceptions of the affection.84' MENTAL DISEASES that supervene are the opposite of those ob- The symptoms served in melanchoha. symptoms depend This statement necessitates a brief analysis. comprehended unless melancholia were studied states so depressive this commonly precede the evolution of mania that sequence of study seems to It has just me to be. be true that in mania we have an opposite condition. the patient may write letters. These are exaggerated in style. a man who usually reserved. time. fact. . clinical portrayal. In the early period. quiet. Instead of being mute or chary of speech. this not the case. the speech. be should. a painful emotional If it state. he is now talkative and even noisy. indeed. symptoms may be properly understood and if Few a any writers give due weight to the fundastate. Further. mental facts of the manic and content themselves with a mere recital. and often. is Instead of being quiet and listless. ecstasy.

its it concerns itself not with its own feelings. he does not say "I feel well. closely though he were still. for the mind upon itself is or upon own pro- stream of thought outward. objective. His style is boastful. as of spirits. is with own ego. boastful. in the best This attitude. let us turn our attention to the symptoms more tion is in detail. better this tone of mind. but fastens his attention his upon nothing. as already indicated. CIRCULAR INSANITY 85 for joy. in we have a second flow fact the exact opposite of that melancholia. is boisterous. He laughs and frowns in quick transition. His manner heightened. In keeping with the objective mental attitude. patient. his his conjunctiva tense and brilliant. There its no concentration of the cesses. his his gestures extrav- movements agant. The mental atti- tude of mania it is is the opposite of the attitude of melancholia. indeed part of. The patient does not feel tell us how he feels.GROUP II —MELANCHOLIA. In mania they are unrestrained and massive pour forth hke a torrent. buoyant. I good. Here. in restrained. his expression animated. He or. happiness. is The in constant motion. is associated \vith. sluggish. of melancholia. tric. mind just as MANIA. aggressive. number and may With these two facts before us. One of . the psychalgia. retarded. he rapidly embraces the objects and persons in a room in the scope of perceptions. His thoughts flow with great rapidity and he constantly gives vent to them. color are coarse is and exaggerated. again. and we will assume that our atten- directed to a typical acute attack. He talks incessantly. declamatory. acts as though he were elated." but we infer from his conduct that he has a sense of well-being. an egocen- attitude of much as do the depression. another symptom. but with the external world. that of the heightened flow of thoughts and impulses. I feel fine. and ecstasy imply a subjective. the soul-ache. namely. their In melanchoHa thoughts and impulses are is inhibited.

attitude. The stranger is spontaneously associated with persons the patient has previously known. object. as to the identity of persons and the character Strangers may be greeted as old acquaintances. and rapidity is and especially to an association that unusual. the surroundings. every combines with the individual before him. Illu- which these objects have no sions of perception thus constantly occur it and are more frequent. tone of voice. The illusions are ently due in part to the fragmentary and imperfect character of the perceptions and in part to the abnormal associations aroused. Again. number of g. . multiple and crowded. too. It It cannot be attracted for any but the briefest period of time. objects. but also to misplace the latter altogether in time and place. the room in which the patient finds himself. gesture. bizarre. the patient sees the doctor or an attendant. or what not —evoke in the patient's mind associations. at once some quality or qualities of the latter e. bizarre ideas with may serve to evoke numerous and relation. clothing. as regards persons than as regards The significance of these illusions and the fictitious memories they arouse becomes apparent as we speech. Thus. Trains of ideas are thus aroused which the patient Similarly. color of hair. that cause the patient to mistake. listen to the patient's Soon we become aware that the disturbed mental processes are in part owing to an increased ease of association.. often frankly abnormal.— 86 MENTAL DISEASES is the striking features of mania this fault of the attention. not only the identity of the person. or associated with incidents with which they have no connection. is fleeting and fragmentary in the extreme. The things about the patient. becomes a point of departure for equally numerous appar- and abnormally related associations. would appear. so rapid and hasty are the acts of perception that the patient constantly makes mistakes of objects. addressed by familiar names.

than associations of meanings. especially this sound association. unexpected. mental faculties is The supposed exaltation of the soon found not to be genuine. more particularly the neuraxones. Often they seem witty. evanescent. cell In the case of many neurones. and the seeming richness of association often degenerates into the stringing together of merely similarly sounding phrases. to play upon words. while listening to a case of mania we are impressed with the enormously increased l^ut. the restlessness and incessant speech. The more the case develops. It does no violence to the facts to suppose that. become. the The thoughts are. as the case develops. not so rich in ideas is as in words. MANIA. The phenomenon in of the enormously increased association mania is. words. or syllables. Further. after all. instead a real paucity of ideas develops which becomes more apparent as the case progresses. tense motor It legitimate to infer from the in- excitement. we are also impressed of by the changing. when we pause to reflect. to make puns. that nervous discharges pass in great volume through the effer- ent branches of the neurones. in the peculiar morbid state of the neural protoplasm. such as sounds. unessential character thoughts. the more evident does this coarse association. nervous energy is evolved with unusual ease and It is flows with lessened resistance along the cell processes. in keeping with the heightis ened nervous outflow. often they appear as attempts to rhyme. flow of ideas. the collaterals and dendrites. all of the processes serve this function. but it is also legitimate to infer that an overflow likewise takes place through the other branches. CIRCULAR INSANITY 87 The associations impress one as striking. It is doubtless upon just these structures that association normally depends.GROUP II — MELANCHOLIA. the wonderfully increased association found to be rather the association of coarse qualities. doubtless diffused through the nerve tissues far more rapidly .

what we hear may of words.0» MENTAL DISEASES in this and readily than normally. when beginning. We can understand why. amount of In mania such acts take place with abnormal speed and in abnormal number. he passes with leaps and bounds from one thing to another. the non-con- secutive character of his thoughts. Fatigue of the finer collaterals and dendrites may also play a role. and probably along the larger pathways in which a lessened resistance is encountered. but also to those of a disturbed asso- ciation. to pathologic associations. under these conditions. becomes incoherent. may be more apparent than . why the associations should lose and finer qualities. so that as the case progresses coarse and flaring associations only are presented. and often is. It can readily be understood that in acute mania the current is of ideas never uniform. Indeed. It word cannot be surprising that under these circumstances. to bizarre. even may not be present. the disturbance of association and the speed of his utterance. their intimate. due to the inconstancy. why they should become coarse or relatively so. Probably upon these facts depend the coarseness and superficiality of the associations. that he be. Normal acts of association re- quire time. the overflow should pass along unaccustomed channels and thus give rise to unusual. real. He jumps from to phrase. merely a disjointed torrent In the early stage of mania. The discharges are doubtless dif- fused en masse. so rapidly that his speech can Soon his ideas may flow no longer keep pace with them. We can also understand. elaborate. and to the way gives rise not only motor phenomena. The patient is incapable of carr3nng on a special train of thought or giving quiet and adequate consideration to any subject. one sentence into another. incoherence and. passes from phrase to word. and probably so in proportion to the detail. perhaps.

or consequence manifest themselves. Transient ideas of constantly greatness.GROUP and it II — MELANCHOLIA. Hallucinations. may mani- strength and powers gen- He is boastful. However. incoherence therefore. but they are not evolved into well-formed delusions. is the entire attitude emissive. and persists more or less during the active period of the attack. . However. in typically acute cases. may never occur. he fest excessive notions as regards his erally. relatively mild. is The patient is so taken up with that which going on about him that he either does not observe or if pays no attention to hallucinations present. only now and then. Suffice it to say. however. They do occur. in cases that are ances of the patient throughout. but nothing of this kind occurs in mania. Delusions as such play no role in mania. MANIA. Least of all are they systematized or fixed. the patient seems to have an expanded sense of well-being. importance. some degree of introspection and analysis. ambitious. does he react in a way which justifies us in assuming their existence. Sleep. is Usually for a time abolished altogether. of It does not. form a necessary symptom it is mania. they shift with the constantly changing and illusory perceptions and manifold associations. CIRCULAR INSANITY 89 may be possible in large measure to follow the utterFurther. that in by far the larger number of cases they are clearly not present. not only established but becomes marked as the affection progresses. but their occurrence is only occa- sionally noted. erotic. form no part of the chnical picture of mania. insomnia stubborn and resistant. also. objective. during a relatively quiet period. as it is might be expected. a fact which the previous discussion might well have led us to anticipate. is greatly disturbed. lusions De- presuppose reflection.

and attempts frantic attacks Happily outbreaks of such severity are infrequent. somewhat more common among women than among men. indulges in indecent acts gestures. and vituperation. the slightest cause may provoke measure tractable. quite frequently the patient is erotic. may later become exceedingly violent. At the best. and may strip himself nude. on those about him. He may urinate or defecate upon the floor. it nevertheless they would seem. some- times he rubs them into his hair. exceedingly violent altered. The patients often give vent to muscular efforts. . The physical signs lessness may be enumerated briefly. strength it seems. may tear his clothing. to be actually increased. during threats. upon the walls of his room. in the degree of their intensity. Every- thing denotes a loss of inhibition. and uses obscene words and expressions. it at others. he may remove and altogether. He may become combative. and prolonged. the symptoms sug- gesting perhaps. exposes the person. pleased. occur and are. especially at times. Sometimes he wears his clothing in some grotesque fashion. One case may be relatively mild. explosions. The restmay be accompanied by an exaggeration of the muscular . which he curses and shouts. his mouth. gives vent to his abuse. The tendon reflexes are not especially The cutaneous sensibility appears to be diminished. filthy. He may also become from his indifference or inattention to his necessities. and obscene. Sometimes he becomes wildly destructive. his ears. the manic patient is untidy and dishevelled.90 MENTAL DISEASES Cases of acute mania differ of course considerabty from each other. language is profane. Masturbation filthy too may be practised. In others the excitement patient in a may reach a very high is degree. as just stated. The and who early in the attack good natured. an alcoholic intoxication. Sometimes he smears the dejecta sometimes upon his person.

quite evident. which in is diminished or abolished in melancholia. sometimes has a distinctly greasy and sticky and skin is is said to suggest the odor of mice. and accurately. The saliva secretions are but slightly changed. The special senses it appear to be more acute than normally. many is patients are con- tinually spitting. exaggerated mania. so. the tongue becomes clean. CIRCULAR INSANITY 91 is this the case with regard to impressions ordinarily painful. also true of heat and Doubtless this indifference again to be ascribed to the emissive. though this is the exception. rarely it is The temperature is usually normal. the "extraneous" mental attitude. slightly subnormal. possibly a diminution of the phosphates. at times even red and glazed. as has already been pointed out. and even more serious inthis is is juries receive little or no attention from the patient. the tongue is coated and there constipation. usually more so in periods it of increased excitement. the may be increased in amount. bruises.GROUP especially II — MELANCHOLIA. constipation disappears. The it perspiration also in some cases infeel. The is appetite. sometimes excessively the patient eating glut- tonously. A rise of temperature always indicates a visceral complication. Later. the is dry. creased. cuts. cardiac impulse is The force of the usually increased. At other times. . However. MANIA. that he does not perceive clearly correctly. but the chemical examination reveals of no changes moment . The pulse is somewhat rapid. cold. contusions. perhaps would be more correct to say that the patient reacts It is inordinately to visual and auditory impressions. As the attack progresses usually becomes somewhat slow and often small. does not interpret his impressions Digestion is is at first impaired. The urine likewise increased in quantity. but the vascular tension appears to be diminished.

namely. is As in melancholia. only occurs the mania has become complicated by the confusion usual of exhaustion — itself un- —and e. need hardly be pointed out. it may gerated. The excitement gradually the sleep improves. little may little is begin to decline. but sometimes intermittent. about two. Diagnosis. as in melancholia. On the whole. it is shorter the severe the attack. Marked impairment when memory. though. in health. severe to- marked exhaustion. the is course of an attack of mania not always uniform. in a large measure. or —the symptoms subsides. The patient is often. —The diagnosis of mania offers no special diffi- The character of the attack.. remember subsequently the detailed events of his degree. a true hypermnesia illness to a surprising of may exist. g. MENTAL DISEASES women If irregularity or suppression of menstruation is is the the menses appear.— 92 In rule.. i. especially in cases. three. in a first attack. therefore. memory be exag- mania may be better than e. he may. at other times the return to the is lucid state sudden and abrupt. or four months. three. four. culties. Sometimes the convalescence irregular and interrupted. The duration be of an attack of mania is. That there gether with is loss of weight in the course of an attack. there apt to be an exacerbation of the excitement. the patient gains in weight. it may more much longer. the rule obtains that a manic attack is shorter than one of melancholia. After the maximum period of symptoms has more months lasted for some time two. it should be added. the absence of hallucina- . An in important fact remains to be noted. Other things equal. and by again becomes normal. is then clouded only for the period during which this confusion existed. cognizant of his surroundings throughout.

it is the opposite of the subacute form of melancholia. its or visceral complications is occur. and there can be no doubt as to the position which it should occupy in our nosology. The milder cases can with equal ease be differentiated from the expansive form of paresis. than a persistent "manic" excitement. as in a patient of the writer. Sometimes the attacks are few and far between.GROUP tions II — MELANCHOLIA. more frequently over several years. served wath an interval of ten years. Hypomania Like melancholia. —The prognosis is. however. too. distinctly the exception. Hypomania forms a well-marked sometimes clinical entity. relatively high degree of lucidity serve to differentiate from delirium. there are transitional forms between it is and mania proper. which is accident. as in melancholia. that possessing the disturbance. Death from exhaustion. Prognosis. CIRCULAR INSANITY 93 and delusions. it is a prelude to the latter. it however. and the it MANIA. in the majority of cases. Very often. The intervals between attacks sometimes extend over a few months. . a higher level Occasionally mania does not rise to is. Like congener. never equals in intensity the acute form. the reader is For a further consideration referred to the paragraphs on the prognosis of manic-depressive insanity at the close of the present chapter. In way. clearly but a phase of circular insanity. by the absence of the physical signs so characteristic of the latter affection. but itself in may occur in a subacute form. Such long however. may. hypomelancholia. mania an affection essentially recurrent. mania does not always present the form here pictured. while the essential features of its mania. of this subject. in whom two attacks were obintervals are. a form termed hypomania. favorable as regards the mdividual attack.

occasionally the patient passes abruptly from one theme to another. does little not answer. becomes involved. — The is onset of an attack of hypo- mania is probably always preceded by a depressive phase in of a melancholia are which elements more or less discernible.94 MENTAL DISEASES S3nnptoms and Course. business enterprises. is tude of mind. he recalls events readily. There is is the same objective and emissive attithe same restlessness. However. the same or similar may be early observed until the manic is becomes marked. he loses patience. abnormally increased. there as before. give an appearance speech. Occasionally. if questioned much. In spite of the general mental exaltation. not so pronounced. im- pudent or ironical. The excitement. he shows no not neces- appreciation of the obstacles in his path. too. but they do so with abnormal rapidity. and usually odd and striking. He expresses himself with ease. however. the altitude of the decidedly lower than in mania proper. which sentences are broken. speech cannot keep pace with the speed with which the ideas flow. he of originality and brilliancy to the patient's or. though. is Association. but is is far less marked. it may seem witty or humorous. or scientific or literary under- takings out of all proportion to his resources. wave is relatively limited. in repartee. It symptom is may. however. may be. inventions. gaps occur and perhaps a in incoherent. The intellectual exaltation. The expansive mental same emotional and vagaries in conduct state state gradually established. replies quickly. The abnormal psychic The activity also shown in other ways. the thoughts may follow each other in orderly sequence. this owing to the lessened degree of excitement. It does . and a condition then results which reminds us of mania proper. and may indulge His he is memory is active. patient engages in or proposes various ambitious projects.

his inventions. the exalted. CIRCULAR INSANITY 95 sarily follow that his schemes. extending . or social position. and covering the entire period of his stay at the asylum. in audacious advances. are less acute. in his normal condition. The patient's feelings and moral sense. may drink to excess. manifests for them the same affection as formerly. frequently reveal betray marked sexual excitement. becomes pregnant. in memory may be much is many cases remarkable hypermnesia present. as already stated. his poems.— GROUP II — MELANCHOLIA. alienis ates by his ill-considered conduct. The ters patient recalls historical events and dates and other mat- with great accuracy or quotes word for word from books sometimes whole pages —which he has not read patient for many years. he no longer often he circle. itself in Their eroticism may wearing striking apparel. are devoid of value. irrespective of his age. too. the unfortunate patient sometimes. including his arrest and subsequent commitment. in open solicitation. in making violent love to any man who hap- pens to be near. and may subsequently give a all remarkably detailed and accurate account of during his illness. Women. Sometimes engagements to marry are entered into too. as in mania proper. also. they reveal grave defects judgment. however. MANIA. The may also observe his surround- ings with abnormal minuteness. recall and little of which. he lose all may give free play to his sexual instincts. He is apt to neglect his family. suspended. may commit acts openly his which compromise reputation. he can usually or nothing. His moral sense. reserves his ill humor and fits of anger for the home To strangers he may by appear as a person of agreeable maimers until he offends his egotism. . of Usually. fatigues by his loquacity. In hypomania. that occurred One of my patients dictated to a stenog- rapher the detailed daily events occurring shortly preceding his illness. fitness. may reserve.

abandoned by his attorney. a woman who was in a condition of ex- treme eroticism.. The recrudescence of sexual feeling constitute the most striking may be very marked and may symptom of the case. is that he does not satisfy her sexually. while she herself is perfectly healthy and in various ways intimates or broadly states that both her desires and her . maintained that the fact that he to his alleged insanity. He entered suit against his physicians. For instance. that he indifferent or incompetent. e. his suit came to naught. was being illegally restrained of her Her case was promptly taken up. both friends and physicians were subjected to considerable annoyance. in cases of hypomania. held at the asylum until the manic wave had subsided. notwithstanding. a woman who has been absolutely chaste both in thought and con- duct and apparently happily married for years. early need hardly be added that. was prima It facie evidence that he had been sane throughout. and had committed flaring acts of solicitation.96 over MENTAL DISEASES many months of time. She communicated by letter with the mayor of the city and with a prominent attorney. alleging that she liberty. In another instance of hypomania. and. in the early forties. and pubhcity —and It is what was to the relatives scandal and disgrace —was avoided. a remarkable fact that sexual elements play an especially prominent part when the hypomanic wave occurs as the middle period of life is approached. she was. Meanwhile. was as a last resort committed to an asylum. As happens not infrequently. in remembered everything pertaining such minute detail. the patient claimed that he had been im- properly committed. g. among other things. complains to her physician that her husband is not as attentive as formerly. the general m^nic features being relatively less prominent. but after a time both mayor and attorney were convinced that she was insane.

gross breaches of conduct. In hypomania. in order. physician or other person whom she has freIn such case. her advances. to life. tear off his buttons. often open and un- quently met. sometimes accompanied by frank avowals. and. concealed. lawyers and physicians are is alike appealed to by the patient. Sometimes vague ideas of persecution make their appearance and may is lead to acts of violence. scandal and elopement in love be her may follow. satisfy her scruples and to be in keeping with her previous may give to the affection a platonic I coloring. very curiously. it may minister. CIRCULAR INSANITY 97 capacities are very great. the clothing of the patient may be disarranged or dishevelled.— GROUP II —MELANCHOLIA. attempts at control are resented as unwarranted interference by both men and women. physicians also and —who will take up the supposed cause of the patient. the patient. unfortunately. approxi- mates that of mania proper. infrequently with some one j^ounger than herself. turn his coat inside out. thrust his trousers into his stockings. Advice and admonition are alike rejected. if Especially is this apt to be the case the excitement is is pronounced. know of no cases more difficult of management than cases of hypomania. When commitment to an asylum finally the only way out. cause no Sometimes small embarrassment to the persons concerned. Sometimes may put on his clothing in a grotesque manner. It is but a step farther for such a it is woman much to fall in love. Not MANIA. intrigues. and so great the apparent lucidity that attorneys will always be found for that matter. may make finger-rings or bracelets out of pieces of string or . it would seem. as in ordinary mania. or in such instances the patient of long duration. At times the patient falls with some one whom she has greatly admired. circumstances great harm best interests That under these may ensue to the patient and to his may well be imagined.

and the relatively high degree of lucidity leave differentiation no the room for doubt. dried leaves. or dirt into his nose or ears. signs are absent is in hypomania as in mania Sometimes there a slight tremor of the hands. and a half. a year. he collects and puts into his pockets the objects. due to the hurried speech. In some cases it would seem that the condition never entirely disappears. MENTAL DISEASES Often. most miscellaneous stumps of cigars. Sometimes he scatters or ar- ranges such objects about his room. in the majority of cases the patient becomes normal for a time. would seem. never.98 yarn. the absence of hallucinations and delusions. however. too. or nails. pieces of paper. Physical proper. but the weight usually below normal. after months another attack. as already stated. The appetite is good. is is much much lower. the duration of an attack of hypomania eight months. in so far as it is wave-like. a year longer. Diagnosis. the patient betrays a faulty enunciation. their lives. are somewhat "manic" II. The subsidence is usually gradual. suffer later but only to or years —from The —perhaps soon. The course is like that of ordinary mania. fragments of rags. made without diffi- expansion. perhaps is. Again.) However. the emissive and objective attitude. the anomalies of association. rags. the atactic speech of paresis. or perhaps from an attack of melancholia. A from paresis is made by absence of physical signs and from the expansive stage of para- . all of (See Part Chapter III.— The diagnosis culty. two years. as a rule. or more. such as fragments of bread. Neither the digestive tract nor the circulatory apparatus reveal special is symptoms. or stuffs hair. it such individuals. pieces of glass. though the altitude of the wave. at other times. strings.

this usually of uncertain length. that of the second three. though less so than in the acute form. insanity of double form. an interval during which the patient normal or relatively The direct transition is perhaps more frequently observed.. g. periodic insanity. an acute attack of melancholia may be followed by an acute attack of mania. Further.GROUP II —MELANCHOLIA. though in cases at should be made and fluid. Two widely different phases present themselves. a hypomelancholia may may alternate with a hypomania. As may be inferred from the sections on melancholia and mania. i. MANIA. it is usually unnecessary. Again. the transition from one phase to the other direct. we will say. they may alternate with each other in various ways. or is may be there may be so. without any appreciable interval. The two phases form a cycle. almost every order of succession has been observed. . the dura- tion of the first phase being. into the it is detailed consideration of which unnecessary to enter again. a hypomelancholia precede an acute attack of mania. per- haps intense in degree. should include both the blood and the cerebrospinal Prognosis. the melancholic wave is somewhat longer than the manic. the waves being of equal altitude. e..) —The prognosis as regards the outcome of the individual attack is. on the whole. (See section on Paresis. favorable. is characterized by an alternate succession of attacks of mel- ancholia and mania. is If there be an interval. CIRCULAR INSANITY 99 noia by the absence of the systematized delusions and other cognate sjonptoms unnecessary to detail here. e. CIRCULAR INSANITY Circular insanity. A serological all examination doubtful. or an acute attack of melancholia may In be followed by a mild and prolonged wave of hypomania. However. four months. thus.

two phases constitute a cycle. on succeeding days. half. they are very much less aUke. Very such a cycle may occur only once in the is lifetime of an individual. As already rarely. may at once be followed on. and so In other words. cases present themselves. given. a year.. A cycle may embrace It this a number of months. indeed. both as to verity and duration. the said. it may be. . that the manic phase attention is may be the first in the series. prolonged and extends over several Further. always preceded by a depressive phase. that Finally. be added. there MENTAL DISEASES may be no correspondence whatever in the altitude or duration of the opposite phases. sometimes. period during which the patient is normal or relatively it is This period may be short. though infrequently. as it is and this is the more frequent also the less distressing form. frequently they vary decidedly. the paAgain. but not infrequently years. or . it is stated. however. e. a year and a cycle. or in which elements of depression and ex- pansion are present during various periods of the same day. by another and by a third. the various cycles are separated from each other by a so. first the suc- ceeding phases are short terval is —when the cycle It should is itself is —the to in- apt to be lacking. in brief intervals. the which There it is reason.100 other words. i. is However. as al- ready shown. to believe. tient may suffer from a continuous circular insanity. the successive cycles se- may bear a general resemblance to each other. the truth doubtless that such an observation merely incomplete and takes no note of mild melancholic and manic waves that have occurred previous to or since the frank attack. When short also. or longer. change between night and morning. which depression and expansion alternate at very for example.

MANIA.GROUP II — MELANCHOLIA. THE PROGNOSIS OF MANIC-DEPRESSIVE INSANITY IN GENERAL General Conclusions. the prognosis is of an individual attack of melancholia or of mania the patient. these two phases do not. during the subsidence of a melanchoha and the. the absence of stupor. As regards the manic phase. As regards the melancholic phase. manic-depressive insanity affection. phases of melancholia may be succeeded by phases of mania and vice versa. i. as yet. —The following is facts. however. Further. and the absence of marked disturbances of nutrition. presents itself in another Clinical experience has and far more serious aspect. this true of the attacks that occur in early life.. incompletely established phase of a mania. is. Especially is good. we have among the most favorable indications the typical and acute character of the attack. by any means. ical Thus. the outlook is again more favorable in proportion to the frank character of the attack and the moderate degree of the exhaustion. occur with equal frequency. Third. Second. The subject. an increasing experience shows first that. already pointed may be considered as established: First. one one in which both the melanchoHc and the manic phases occur. it is undoubtedly a fact that typless acute mania occurs much frequently than typical acute melancholia. shown that the attacks Isolated attacks are of both melancholia and mania recur. in cases which appear at sight to be merely recurring . while to all intents and purposes. e. excessively rare. for instance. likely to recover from the attack. CIRCULAR INSANITY 101 in Such cases have been described as the "mixed" form and are the larger number of instances to be observed during the period of transition from one phase to another. out. other things equal.

. but they recur with a diminish- ing frequency and diminishing intensity. intervals which sometimes extend over many months mania and years. cases of melancholia are time which the patient must be regarded as entirely normal in the intervals. as regards the manic attacks themselves. let us repeat. delusions hypochondriacal in type. a highly evolved special delu- sion of the unpardonable sin. The less fact remains. as we have already pointed out.. have life. these intervals are very frequently periods of mild manic elation. other things equal. clinical the following generalizations: First. e. and more melancholia of middle life. may not be present. namely. are in the older cases more frequently met with and reach dle life. Acute manias. i. that acute occurs much frequently than acute melancholia. The detailed picture of first attacks may differ in this respect from second or third attacks. a review of the clinical findings also justifies the inference that recurring attacks of melancholia tend to increase in duration. and again met with in Finally. perhaps are at most an approach to hypomania. that they occur more frequently and with greater intensity in early life than later.102 MENTAL DISEASES attacks of melancholia with normal periods intervening. notwithstanding. somatic delusions. Second. their typical development in the melancholia of mid- Third. are present in great force. experience appears to justify As regards melancholia. their first onset most frequently in the third decade of they recur subsequently.. they do not constitute well-developed attacks of mania. frequently. it happens that. psychic suffering. each successive attack is. clinical experience justifies another generalization. cide. such as is met with in later attacks. and rare as the middle period of life is become quite approached. particularly from the ^ e. Again. in the attacks which occur early in hfe. self-accusation. while the general tendency to sui- symptoms. than in the younger.

a Sometimes the history to light in of recurring phases of manic activity brought middle life is a case of melancholia of most striking. has been with the writer an almost unvarying experience that is when a melanchoha in occurs in middle life i. clearly proves that the middle-age first melan- which is perhaps the a attack which leads the family physician to call in specialist." frustrated. frequently be found that he has suffered from periods of depression previously. by a period of ill-health. instead. perhaps. each period brought to an end.— GROUP II —MELANCHOLIA. Such a history is most suggestive. The of my patient was clearly featured by hypomanic states. If the life history of it will the individual be carefully studied from early youth on. of attracting the attention of I members Not infrequently have unearthed clear histories of waves of depression recurring at intervals and of many months' and in duration. in the While there are Certain it is main are correct. that attacks occurring in middle life much more prolonged than attacks occurring in early Further. and often to the degree of the family. it life. Sometimes the history reveals clear history of reactivity. 103 somewhat longer than the preceding exceptions to this rule. is by no means the first attack early of the affection life from which the patient has suffered.. The writer believes that the more the phases of . CIRCULAR INSANITY attacks. said to have begun middle life —a careful study of the personal history will show that in reahty the attack from which the patient suffers is not a first attack. with lack of progress and indifference in the intervals. not pronounced. interlarded perhaps with states of depression relatively insignificant. a peated periods of long sustained and abnormal em- bracing great enterprises and projects. it is MANIA. In one of my patients enormous business success ensued during these periods. e. achievement ''breakdown. and cholia. but nevertheless existent. a most surprising way.

of middle in life. the attacks conor. persist into old age. the patient presents . women some of whom subsequently develop a middle-age melancholia. The was writer once had under his sisters. In other cases. whether life. the history are more will the conclusion be justified that. violence done in attempting to sepaa so-called melan- form for middle life. aged suffering from a typical long- drawn melancholia her junior.— 104 MENTAL DISEASES occurring in a life depression or of expansion studied. CHnical experience has shown that patients pass through manic and depressive attacks without oration. a manic state is sometimes found either interlarded between phases of depression or existing perhaps as a well-defined hypomanic wave. indeed. at one and the same time. while the other. as excitement. Like the melancholia. and that rate out a special clinical cholia of involution. —and yet even here recoveries may Another important question remains to be considered. Some- times. two years was confined a neighboring asylum with a typical attack of mania. Manic-depressive insanity of the patient. manic wave burns with a fierce brilliancy. but it does occur. two forty-six. and eroticism some- witness the hyperactivity. become chronic. suffering any mental deteri- When the phase has subsided. perhaps in the form of Occasionally phases of hypomelancholia. again. Again. continue to recur. occurring early or late in they belong to one and the same is symptom group. Sometimes they come to an end with one or two prolonged attacks of melancholia in middle life. the mania was of long duration and unpromising. it is just in old age that profound waves of melancholia occur profound and persistent ensue. times met with in women in the early forties. one of whom. may persist during the lifetime rarely the attacks cease to recur. care and observation. this it is rare. in middle life.

abuse. When recovery ensues comnot However. Not infrequently they are accompanied by visceral and other hallucinations. as a secondary There may be a persistence of depressive delusions. the mental impairment that ensues in chronic cases amounts to a true dementia. an attack or of melancholia occasionally extends over three. should be emphasized. sometimes clearly outlined. to become grotesque. In states terminal to mania an analogous . recovery is now and then clearly not complete. that is. like many another general truth. They may consist of ideas of ill treatment. sometimes paranoia. there are a certain number. however. seen an excellent recovery in a woman At suffering from a middle-age melancholia after four years. In time they are likely to undergo degeneration.GROUP II —MELANCHOLIA. plete. both with recurrence and with increasing age. of exceptions. if more years. as already stated in regard to melancholia. it is absolute. of loss or MANIA. an unfavorable sign. four. times. there is a distinct and persistent residual mental impairment. the attacks tend to increase in duration. Again. the writer has. and may resemble those of a paranoia. there a distinct tendency to the pro- longation of the attack over an increasing period of time. sometimes vague. a so-called secondary or terminal dementia. to this it must now be becomes less added that the prognosis assured as middle age is of individual attacks least so approached and is when middle age is reached. The appearance is course of a melancholia always. 105 no evidence fact is impairment of any of all This one of the most striking in the varied phenomena it is presented by mental disease. a very small number. though improperly. absurd. this is spoken of. and even persecution. First. Finally. CIRCULAR INSANITY his faculties. Second. hypoof a paranoid attitude in the it chondriacal. The delusions may become more or less fixed. offering so it is to be fairly regarded as chronic and as but little hope of improvement.

but in manic-depressive insanity neither Fauser nor others who have investigated this field investi- have ever found defensive ferments of any kind. the toxicity secretion. manic-depressive insanity appears to be due to a quantitative rather than to a qualitative change in substances normally present.106 picture of MENTAL DISEASES may be presented there . but rather that an excessive or an insufficient production of is some normal not formed. against which a defensive ferment in In other words. pineal. and the gations have included the sex glands. The mental states suggest the influence of a toxin of the — possibly an autotoxin. It liver. kidney. the failure to properly differentiate melancholia and mania from the excite- ments and depressions met with paranoid group. nificance of this fact. . the pituitary. muscle. tissues. both against the sex glands and against the cortex. To appreciate the sig- we must bear in mind. as will be pointed out again. the thyroid. an examination serum of the blood has failed to reveal the presence of any defensive ferments. many instances. suprarenals. with mental impairment. the force of Of this truth the familiar instances of hyperoffer striking and hypothyroidism examples. but this to was doubtless owing. the outcome of these affections. Such ferments. have been found dementia prsecox. was much more common than at in present. in However. cortex and other would seem that in manic-depressive insanity a is coarse dysfunction of the cortex there is not present. In former years the diagnosis of chronic melancholia and chronic mania and of terminal dementia. in the members of the heboid- In regard to the pathology of melancholia-mania is little that definite can be said. that substances all present in excess or abnormally deficient have poisons. may be an indefinite persistence symptoms and of ambitious or expansive ideas poorly ar- ranged.

treatment directed to the digestive tract has uniformly failed to of the modify the progress Finally. CIRCULAR INSANITY 107 it In any event. . whatever the disturbing cause. must be endogenous. theories symptoms in the slightest degree. a symptom of defective innervation. MANIA. have also been formed ascribing a psychogenic origin to melancholia clearly inapplicable in and mania. of this there can be no doubt. for manic-depressive insanity bears no relation to infectious processes or other poisonings of extraneous source.GROUP II —MELANCHOLIA. It has sometimes been attempted to refer the affection to gastro-intestinal auto-intoxication. but such theories are affection which is an essentially hereditary and innately neuropathic. but the gastro-intestinal atony is itself an outcome of the disease.

a so-called paranoia. to deal with individuals It would seem that we have here who are defective in their organization. but serves to distinguish from the other groups. therefore. included. as this insanity. by Schott. Paranoia) The group considered in the present chapter consists. the breakdown may not occur until the form adult of life has been reached. of affections essentially degenerative in their nature. as already indicated in Chapter II. All observers are agreed as to the large proportion of hereditary factors. as we will forms a natural whole. I group includes both juvenile and paranoid have for some years applied to it the designation of see. This group. a so-called precocious dementia. to 90 per cent. the heboid-paranoid group. The wide is variation in the percentages of different observers probably due to differences of view as to what should be first. These are variously estimated at from 52 per cent.CHAPTER V GROUP III. secondly. as to 108 what affections should be included in the general .—THE HEBOm-PARANOID AFFECTIONS (Dementia Prsecox. and. when it presents itself in a delusional insanity. or. though composed of a forms. in the general term of hereditary factors. living. number of clinical The term heboid-paranoid is it not only in a sense clearly descriptive. it The breakdown may occur early or and then pre- sents itself in the form of an insanity of youth. Inasmuch. by Zablocka. with persons who have had transmitted to them from their ancestors a structure so imperfectly or so aberrantly constituted that it breaks doAvn under the mere strain of relatively early.

misfits. but also the occurrence of eccentric or unusual personalities. vagabonds.— GROUP III —THE HEBOID-PARANOID AFFECTIONS 109 conception of dementia prsecox. It is significant in this connection to note the varied character of the facts presented by the ancestry as compared with the relatively limited and definite character of such findings in manic-depressive insanity. however. which he again regards as too low. yielded 33. of his cases. manic- depressive insanity. this may possibly have been too high. such as epilepsy and hysteria.. Dementia prsecox only infrequently directly transmitted from parent to child. all we should note departures from the normal. not only are instances of dementia praecox met with in the same family. No matter how we approach the subject. prsecox occurs in a number of individuals in the Kraepelin states that he knows a large number of such instances. Further. Personally I have knowledge of one family in which no fewer than five is individuals suffered from this disease. it or severe brain affections in the parents. criminals. in so far as we the older cases under the general caption of dementia praecox. and at times also. suicide. Kraepelin at one time found hereditary predisposition to mental diseases in 70 per cent. prostitutes. This statement must. dementia praecox. comes to the conclusion that dementia prsecox is probably transmitted . from studies made of Kraepelin's material. the facts justify the general conclusion 'as to the relative frequency of neuropathic family histories in In such family histories. He when the inquiry was limited to the direct heredity. though infrequently. that is. and failures generally. tramps. to the occurrence of mental disease. be modified include the paranoid. e.7 per cent. Rudin. but other neuropathic affections as well.. though he thinks that states that i. It is further significant that every now and then dementia same family. as the great is mass of cases develop before parenthood established. of course. not only crass instances of mental disease.

Rtidin noted that suffered late born or last born children more frequently from dementia praecox than others. while the reverse depressive children from dementia praecox to the rare exception. that immediately preceding or following the birth of a prsecox patient there was frequently a history of miscarriage. skull. premature birth. abnormalities of the ears. manic-depressive insanity and eccentric personalities. also evident that other factors which directly and grossly affect the vitality and development of the organism variously play a role. —namely. namely. For instance. the increase of dementia prsecox resulting from inbreeding. imperfections peculiarities. persistence of the intermaxillary bone. and alUed Facts such as the foregoing indicate that in given instances the germ plasm has suffered from impairments that affect general morphologic and biologic properties its and which have growth and profoundly altered and lowered its possibilities of . again. and anomalies of the teeth. Of equal significance are the physical and psychic stigmata of deviation and arrest that are found in individuals who acquire dementia prsecox. retardation of growth. malformations of the deep and narrow palate. a too prolonged juvenile appearance. or stillbirth. Among the latter are physical feeble- ness. In favor of this view he regards the marked predom- inance of the collateral and discontinuous inheritance over the direct inheritance. He found in the families which he studied also other affections. or toes. manicparents— belonged it is Granting the possible transmission of dementia praecox in accordance with the Mendelian law. and further that it was not at all infrequent for manic-depressive parents to produce children with dementia prsecox. fingers.110 in MENTAL DISEASES accordance with the Mendehan law and appears as a recessive quality. and the numerical relation of those attacked to those remaining normal. Saiz states that the frequency of the occurrence of the physical stigmata is 75 per cent.

That syphiUs may play a extremely probable on other grounds.GROUP development. we are obviously unable is it to say. in g. a not inconsiderable proportion of dementia prsecox cases. Diem. first. significance. Fuhrmann. its i. neither impossible nor improbable. It in seems justifiable to assume. Wolfsohn. we have reason to believe. that alcohol likewise damages the germ plasm hardly admits of doubt. Riidin.. alike suggestive and significant. and others have published studies. and it is not necessary that the Wasserit is mann or other tests should yield a positive result. by Bahr in 32. The evidences of inherited syphilis are absent in the great mass of dementia prsecox cases. however. Whether other poisons and intoxications play a role in bringing about damage to the germ plasm. that the evolution of the organism as a whole its — and included in this the development of glands of internal secretion — has been so inhibited and altered the organism breaks that at a given point in its life down by clinical reason of an abnormal and toxic metabolism. but such action event. III —THE HEBOID-PARANOID AFFECTIONS causes which 111 Among may thus grossly impair the germ plasm.. and others have pubhshed suggestive ilis statistics as to the frequency of syphrole is in the parents.1 per cent. are infections Pilcz. a tendency which may . Klutscheff. on the alcoholism of parents in dementia prseeox. Again. is of extreme Such findings do not mean that the patients are suffering syphilis. reaction is The fact that the Wassermann found e. that the germ plasm dementia prsecox may be laden with a direct tendency to the development of dementia prsecox. sufficient that the infection has damaged the germ plasm of the parent. In any must be vastly less important than the action of syphiHs or of alcohol.. from a disease of the nervous system due to inherited but that the organism as a whole has been hampered. made deviate and degenerate in development by the presence e. of the spirochete and its toxins. and intoxications affecting the parent.

and they progressively into . of a brilliant imagispirit.112 MENTAL DISEASES possibly. both causes may be operative together. and possessed nation. and. but rather as a group of mental affections all of which present the one common factor of endogenous deterioration. imperfectly true. to Pinel. to Spurz- heim. the hopes to which they have given rise vanish. are very well at birth. as Riidin believes. can hardly be regarded as a specific clinical entity in the sense as manic-depressive insanity. indicates that the young subjects have reached the termination of the intellectual lives of which they are capable. Thus the latter speaks of children who who increase in stature at the same time that their intelhgence develops. of the faculties. irritable. they rapidly exhaust themselves. and lively. The first cause may be operative without the second. passionate. and an active this activity not being in relation to the physical strength. Surely we have here a picture which strongly suggests the modern conception of a juvenile dementia. he says that an immobilization of all une demence precoce. the germ plasm may suffer from a gross impairment the result of syphilis. in his treatise on mental describes cases which clearly belong to the simple insanities. It of this group have long been recog- appears that the insanities occurring in the juvenile it is period were known. after They live intellectually only up to a certain age. these creatures use themselves up. and Esquirol. secondly. That the second cause may be Dementia prsecox same operative alone seems extremely probable. while they finally pass into a terminal period of dementia. Morel. the intelligence becomes stationary. The various members nized. alcohol or more rarely of other infections or intoxications. who are very sensitive. fall which arrest takes place. be transmitted as a recessive quality in conformity with Mendelian principles. a developed intelligence. diseases. they acquire nothing more. in form of the juvenile commenting upon them.

and Hecker (1877) made a study of the first form. there can be no doubt that hebephrenia and catatonia are not only closely related symptom groups. it While these observers were succeeded by numerous others. already introduced by French writers. It is to dementia prsecox that we will first give our attention. first Morel was the it to use the expression precocious dementia. first used its Latin equivalent. brilliant He thus achieved a generaHzation. themselves into two subgroups. 1874) Kahlbaum he two forms. This does not imply. and was Arnold Pick. one that has served to greatly reduce the difficulty of study and classification. second. who. a position in which he has also been generally followed. a point of view which is now universally shared. and. of paranoid dementias the adults. recognizing the distinction. the the juvenile insanities. not only the relation affections. which he named hebephrenia and catatonia. that these two subgroups are not closely related. dementia prsecox. between these two but also their relation to the various forms of paranoid dementia. was reserved for Kraepelin to recognize. in describing cases belonging to this group. which later named respectively hebephrenia also and catatonia. hebephrenia. DEMENTIA PRAECOX As stated above. Further. while possible to was not separate these two forms sharply from one another. realized that it Kraepelin. The cases of the heboid-paranoid group roughly separate first. INSANITY OF ADOLESCENCE. however. Kahlbaum early differentiated two forms. but that they are also related to cases in which the symptoms resemble . to both conditions.GROUP III —THE HEBOID-PARANOID AFFECTIONS 113 a state which he can only compare to idiocy. and he applied the term dementia prsecox. early differentiated (1863.

a paranoid dementia. The onset number of a juvenile insanity may take place at any life. However. is years of age. sixteen perhaps between and twenty-three be imagined. and in the later period expansion. usually of the character of a confusion. thus. or suggest those of a delusional lunacy.. Dementia praecox males. to include under the designation. It is therefore. which the writer beheves. wise. in the great majority oi cases the affection . There are no incidental factors of etiology. is due to a delayed development. the age. is Kraepelin disposed to include under the last-mentioned term also a large group of adult cases. paranoia. had best be under paranoia itself. but also a para- noia-like juvenile insanity. Having disposed of these preliminary considerations. exhaustion. period between puberty and early adult of The greater cases occur between fourteen and twenty-five. not only hebephrenia and catatonia. neither The fact. youth occurs and life. again. infections nor traumata play any role. a gradually beginning onset of mental symptoms. there present in the early period of the affection depression. praecox —The general features of a dementia : may be outlined as follows first. 114 MENTAL DISEASES i. hypochondriasis. Symptoms and Course. third.. in common classified with others. and with this is said to be somewhat more frequent in my own experience appears to be in accord. but sometimes possessing elements of systematization is second. let us turn our attention to dementia praecox in general. dementia praecox. and this is not surprising when we reflect that in some of these late patients. youth. prolonged into what would otherwise constitute adult in others. or the adult period all come on too early. as may well a variable factor. is difficult of explanation. e. The question of age will again be touched upon in discussing the group as a whole. if true. puberty.

agencies without. change of disposition are noted. fragmentary. Quite commonly they are present in such picture. it is found that he is delusional. is unable to take in new ideas. a stage can be recognized in which the or rather youth. burning. mutilation. there is there an inability to do mental work. It is usually impossible to fix is the time when the affection begins. If he talks. however. ideas of persecution are elaborated. child feels make is their appearance. Sometimes he plays truant sometimes he runs away from home. and thought are alike is disconnected.GROUP is III —THE HEBOID-PARANOID AFFECTIONS 115 progressive. or not systematized at They are painful and depressive of the patient. systematized. to elaborate or properly coordinate is them. chided for being lazy. the insomnia. e. often. that speech inhibited. torture. is He is lacks interest. to agencies in the external world. changing. Frequently the is symptoms are passed by or no attention paid to them. is becomes mentally readily fatigued. so slow initial and insidious the onset. disordered. inat- Frequently such a child tentive. however. his de- lusions.. feebly all. under . served that the patient is ob- slow and heavy mentally. depressed. It is Soon more decided mental changes are noted. complains of being ill. the mental impairment steadily increases and terminates in dementia. poisoning. The child is unable to do its work at school as before. That the patient. Sometimes the speech is suppressed altogether and the patient mute. at other times they are very vivid and characterized by ideas of suffering. sometimes well defined. In the older patients. some- times vague. in character and are referred to causes outside of Sometimes the delusions consist merely ill-defined notions and feelings. headache. Most child. irritability. clearly hypochondriacal. . restlessness. ideas of bodily illness ill. are transient. indifferent. number as to dominate the and they indicate more or less clearly the reference by the patient of his sufferings to i.

but they are an indirect outgrowth of his ideas of persecution. At most they are fragmentary and ill-defined. but hallucinations of the other special senses and of the general somatic sense may may also be present. however. and indeed this appears to be most depressive ideas quent. some patients. In cases that pur- sue a relatively quiet course they nent. is not surprising. in addition to the it other mental features already considered. found. clearly defined self-accusa- moral unworthiness. Sometimes. usually. and quite be interspersed by commonly agitation. Illusions. as a rule. The become less prominent and ex- . the patient evinces ideas of crime. by apathy and emotional indifference. the unpardonable The importance of this distinction cannot be sufficiently emphasized. It may and the patient may in such case become noisy is and much disturbed. commit assault. may is be characterized merely by an absence of spontaneity. sin. MENTAL DISEASES may strike. it marked. In keeping with the character of the delusions. clearly A failure to recognize it may lead at times to errors of diagnosis.116 these circumstances. The ferent depression of the early period varies greatly in difcases both in degree and in the character of the In symptoms. as in melancholia. and we never tion. it is long continued. and it Sometimes the depression very pro- may gradually deepen until the patient passes into a condition of stupor. Sometimes they are very numerous. may not be striking or promi- manifest themselves. manifest fright. also. a stupor that may be complete and may endure for many weeks or months. on the other hand. run away. or may. hallucinations also are found in the majority of cases. Hallucinations of hearing are the most fre- quent. or misdeeds. though they do not. though rarely. play a very important role. ideas of see. or the typical delusion of sin. The mode period of transition from the depressive to the expansive fre- may be gradual.

it. Sometimes the convulsions are repeated. first one group and then the other being more promiis nent until the expansive stage finally established. not by the slowly on-coming symptoms but by some sudden or striking occurrence.GROUP III —THE HEBOID-PARANOID AFFECTIONS it 117 pansive ideas take their place. The change from expansion is the period of depression to the period of i. the cases of hebephrenia and catatonia as well. attention is attracted to stage. accompanied by depression to which expansion sooner or later succeeds. and may be safely claimed. and therefore. in the older patients. this to it Hecker long ago showed clinical experience. and call atten- that the onset of convulsions has served merely to tion to its existence.. just as in paresis. . often unsatisfactory as regards the early stage. epileptiform convulsions are. first also. I depressive phase is am quite sure. The histories of cases are. the disease has pre-existed. seen most typically in the paranoid cases. is Somerapid. the patient in the of ill-health. the truth doubt- less is that. happens that now and then a clearly marked seems to be lacking. however. Sometimes. that this sive period is likely to be the case when the depres- relatively mild and short can readily be imagined. e. as were. is The slowly oncoming mental change. Indeed. both depressive and expansive phases are presented by the younger patients. or may be that during an it interval depressive and expansive ideas are. such as a convulsive seizure. a fact which we presently consider again. it would appear. shows the same to be true for cata- tonia. However. it must be admitted. in rare cases. be the case for hebephrenia. will times the transition from one stage to the other sometimes even sudden and abrupt. com- mingled. that this due to the faulty observation or absence of observation by relatives and others at a time when the patient is is still without medical care. looked upon as ushering in the disease.

However may be. moderate. indeed. that the patient of is under medical observation or. is distinctly the exception. after which the mental impairment becomes more evident. and general mental failure holds good. we must not forget that there are cases in which the outcome is not so disastrous. The question of recovery will again be considered later. as we will see later. after all is said and done. and the patient with a mental impairment which may be very pronounced. is left Finally. and indeed may be long nonexistent during the time . Further. Further. sudden attacks of exhaustion. the oncoming of the expansive stage delayed. that. sometimes of several years. or even absent to such an extent as to justify the opinion that the patient has recovered. from several months to several years. and. cases which . in a limited number of cases it may be so little marked. the disturbed period subsides. but let us emphasize here that a high degree of recovery. enduring and persistent. indeed. after the lapse of months. there may be tia several such recurrences after each of which the demen- becomes more pronounced. The phases depression and expansion extend over a variable period of time. the degree mental impairment having become pronounced. or even from rapidly occurring attacks of stupor.118 MENTAL DISEASES at other times the patient suffers from fainting spells. be safely claimed that the generalization as to the initial depression. Notwithstanding. it may be. however. not only for dementia praecox but for all of the members of of the heboid-paranoid group. I think. there not infre- quently. another onset of a delusional and excited period. the phase of expansion may be evidenced not so this much by ideas as by conduct. and this is the most important point to bear in mind. subsequent expansion. or slight in degree. it may. after a period of is improvement has in a given case ensued.

are. more advanced than that guage is The lan- in keeping with the mental state. or declamatory. perhaps turgid. it is hardly surprising that . This confusional insanity. to say the least. it is filled pressions are excessive. There are present. because of the mode and probably because of the nature of the dementing process presents special features. fragmentary. or with words or sounds As may be inferred from what has been said.. they are puerile to a degree. a toxic agency. a religious. itself. It is exalted and Its ex- bizarre. sional in general terms. indeed.) is For our immediate purposes. like those of the depressive period. and un- related delusive ideas together with hallucinations —a symptom of onset. and in which the final result must be looked upon as a recovery. the elements of a confu- insanity unsystematized. it may be said with truth. it The delusions of the expansive period. trivial words. pompous. an approach to systematization. group which suggests. with misplaced phrases that have no connection. Thus.. (See Part III. with that have no meaning. should be added. too. fragmentary. that they betray an intellectual enfeeblement somewhat of the depressive period.— GROUP III — HEBOID-PARANOID AFFECTIONS 119 — THE are mild. e. clinical simplicity and clearness be served by until deferring the psychologic interpretation of the symptoms a later portion of this volume is reached. ambitious. ill-defined. will best however. however. and not at systematized. on the whole. and may betray ideas quite importance or consequence. e. the mental state preted as a confusion which in some cases i. commonly they have an Quite commonly. because of the period of life at which it appears. of the emotions and other features are present. or poorly They may in various degrees be accompanied of self- by excitement and exaltation. all frequently changing. best inter- in the older or paranoid forms —reveals i. or a political content. in which there are no recurrences. various anomalies of association.

as already pointed out. the tendency to systematization least evident in the hebephrenics. like the lucidity and orientation. and. illusions. and that the catatonic cases were somewhat older than the hebephrenics. slightly more evident paranoid cases. in and early youth. not surprising. that under these circumstances orientation should be well preserved. therefore. for the period preIt ceding the onset. and most developed in the The mode of onset. may be fairly good for events during the early stage. as the affection makes . is especially in dementia which there often a history of delayed and defect- ive establishment of puberty. in the stage of terminal impairment. per- good. the child. indeed. In keeping with these is facts. if such be the outcome. In keeping with the above facts are also the facts of memory. often altogether absent. memory suffers along with the other Again. the patient correctly appreciates and correctly correlates himself with his surroundings.120 MENTAL DISEASES the delusions evolved should be unsystematized and but poorly arranged when we consider the immature condition of the mind of the child at puberty praecox. or stuporous states. Pickett some years ago showed by statistical studies. permits of the preservation for a longer or shorter period of a relatively high degree of lucidity. are established. this lucidity becomes impaired in proportion as disturbed and hallucinatory states. on the other. as already stated. on the one hand. the faculties. may show impairment or loss only during and for the periods of the dis- turbed or stuporous states. especially when the Matter pursues the more common gradual course. Memory is good. are infreIt is quent. Of course. made at the Insane Department of the Philadelphia General Hospital. well preserved. that the average age of the paranoid cases was greater than that of the catatonic cases. in the catatonics. ception is During this relative lucidity.

if told to stand up he may the effort down. talk less may. as already and less. noisy. thus. he sit is may walk backward. standing still. For the same reason the lost. instead of complying with an instruction. ceases to be able to acquire new facts. It is not surprising that the judgment of the patient. tions the patient destructive. stated. the stand-still of mental progress continues. become more and more or finally be- come mute. Sometimes under these condidisturbed. vers4. or is not able to properly coordinate them with those already acquired. the patient or performing other simple acts very much as a person under hypnosis. is —a loss both of the will and the power to perself-control. violent. Emotional their appear- and apathy. he suicide. A stuporous state it may supervene which resembles simple stupor. as does also indifference to the surroundings. lessened or and impulses born of the delusive ideas may be given free vent. the tasks. make ance. present. is There under these conditions — conditions probably of exhaustion and intoxication form the daily inhibition. The patient. too. sometimes. is At times automatism at command walking. performs if exactly the opposite act. If the depres- sion of function. is At other times a condition as it is of negation developed— "negativism" called. if becomes impaired. or he assumes spontaneously fixed positions with its rigidity. may attempt to injure himself or to commit As the affection progresses the patient quiet. a catatonia making appearance. Sometimes.GROUP itself III —THE HEBOID-PARANOID AFFECTIONS 121 manifest. or may be accompanied by automatism. Its the child ceases to comprehend properly and uniformly. may become much and even dangerous. already mentioned. mental reactions and indifference its will become impaired. when made . and vice to change Again. told to walk forward. the patient remaining in positions in which he happens to be placed. especially in regard to new experiences.

effort a limb happens to be held extended or flexed and the made to change it from one position to the other. movements with the hands as there or taps upon the wall Just may be stereotyped positions. then presenting the symptom termed At other times. The patient jumps up and rolls down. bounds about the room. the same phrase out meaning or apparently senseless or sentence — often withfor hours. the patient may repeat the same word or words. Frequently. is probably the expression of an expansive its At times. It about the bed. snuffles. the eyes as well. resisting the taking of food. or clownish conduct. The positions tudes may involve not only the limbs. with the head drawn upon the closed. the patient makes grimaces. Occasionally the patient repeats the same movements fro. or group of movements many gestures. or makes other curious sounds. the restlessness finds vent in a bizarre. and as soon as the its removed and atti- the limb resumes former position. but the trunk and head Patients often chest. the patient's restlessness finds its vent in grotesque and extravagant capers. would seem that the motor excitement here presented is the outcome of a sheer physical exuberance and phase. he rocks to and repeats the same makes the same or bed.122 MENTAL DISEASES marked resistance is the position of the patient. tosses hither and thither. too. lie not infrequently they are bizarre. — continuously verbigeration. in the bed. or in other fixed positions. again. Often he smiles or laughs cause- Like the grimaces. outlandish. the muscles hands of the physician are resist. times. the limbs flexed. feces. the laughter seems to bear no rela- . and retaining of both urine and immobility is Every now and then such a picture broken in upon by an activity apparently as it is purposeless as sudden. lessly. so may there be stereo- typhy of movements. clicks his tongue. If is encountered. silly. In catatonia. claps his hands. giving vent to no word or sound.

shame. He does not. Masturbation is also common The physical signs of dementia prsecox. the early stages. Sometimes the pupils In- imdergo remarkable and sudden changes in diameter. however. of the hght reflex.GROUP tion to III —THE HEBOID-PARANOID AFFECTIONS It is 123 any corresponding emotion. noisily. They appear to be groups of associated movements. urinate upon the floor. station and gait are not altered. as do other de- mented patients. . relation to the mental content. and without proper use Later they become unclean and filthy in their habits. they eat voraciously. equality of the pupils does not seem to occur. especially in the stages of excitement. Early in the affection they manifest neglect and indifference to their persons. regard the symptom as of and does not venture to say that the light reflex is reguis larly exaggerated. they manifest a loss of the finer feelings. or ears. in keeping with other expressions and gestures which seem to bear either no. They appear throughout to be larger than normal. are not numerous. of table utensils. smear the troduce a it matter upon the hands or person. soil the fecal bed or clothing. in- into the mouth. if present. save that at pupils are frequently much dilated. feature. as the disease progresses. are insignificant Disturbances is —Bumke under the impression that in catatonics the pupillary contraction comes on more suddenly and disappears more suddenly than normally. or a perverted. value. may show no The change. in addition to the motor phenomena already considered. affection for their Their hal^its degenerate. the result of the spontaneous emission of impulses which are uninhibited. Reaction to accommodation undisturbed. there is In no tremor. or even nose. sympathy. rela- aesthetic qualities. tives. the tendon reflexes times they are exaggerated. they may. Cases of dementia prjecox manifest their increasing mental deterioration in various ways.



However, a condition which

Bumke would

regard as typical

dementia praecox


the absence of the psychic reflex;




of the

in response to the play of concepts

and emotions;

also the reduction of the pupillary

motiUty and

the absence of dilatation to sensory stimulation.

These con-

ditions appear to obtain in cases already long established,


which there are present psychic enfeeblement and more or
general deterioration.



as a rule,


disturbed, especially during the

period of evolution.


usually diminished at





be increased and even excessive.

There are present quite frequently the signs of an atonic
gestion with constipation;

at other times these features are









find the surface cool, the extremities cold




features dusky, the pulse rate increased; on the other hand, as
in the case of the digestive tract,

no symptoms of moment


be noted.


special features,

should be added,

we ob-

serve in dementia praecox, with a suggestive frequency, enlarge-


of the thyroid gland.

The body weight


as a rule,

decidedly below normal.

As the reader may have

inferred, the pictures presented


individual cases of dementia praecox vary greatly;

that they,

however, present an underlying uniformity and identity

equally clear, and the general description of periods of depression

and expansion, with confusion and


must be

regarded as fairly applicable to
of depression


recurrence of a cycle

and expansion


an interval




this interval

be short so that an expansive wave


or less closely antecedent to a depressive wave,
inference that the expansive



to the incorrect

wave was

first in

the order of sequence; especially



be the case







the initial period of the disease has not been under ob-


The more the

writer has studied the subject, the
of the correctness of Hecker's

more he has become convinced
original interpretation.

As was pointed out
peatedly called to

in the beginning of this chapter,




in our general consideration of the

dementia praecox embraces hebephrenia, catatonia,

and paranoid dementia.

These forms, while closely
clinical features.


present, notwithstanding, special



turn our attention to hebephrenia.


The symptomatology
been already considered

dementia praecox, as a whole, having



detail, it is

necessary only to

point out briefly the special features appertaining to hebephrenia.


begin, in hebephrenia the




praecox are generahzed in type; the characteristics of the



catatonia and paranoid dementia,


i. e.,

there are absent,


or less

markedly on the

one hand, the special motor phenomena



—the verbigeration— of catatonia,


on the

other, the systematized delusions of paranoid dementia.

Second, as


known, and as was shown


by Pickett, hebephrenia is the form met with among the younger
i. e.,

the youngest group of


Consequently, and,

as might perhaps be justly inferred, the degrees of the emotional

departures from the normal are less marked than in catatonia

and paranoid dementia.

In other words, the depth of the


is is

apt to be decidedly

than in the other

forms, and this

equally true of the height of the









illness, of

merely by a sense of

hypochondriasis, the child com-

plaining of headache, dizziness, obscure bodily distress


and manifesting a depression



in degree.


more frequently,

too, in hebephrenia that the

period escapes observation, which would hardly be the


if it

were pronounced.

Again, the expansive phase, while

fest itself

more marked than the depressive phase, may manimore by exuberant and boisterous conduct than by

expansive delusions. As a rule, however, both the
of depression


and the subsequent wave
less so,

of expansion are clearly
in the other forms.

marked, though

on the whole, than

Third, the delusive ideas

hebephrenia wholly un-







this particular the contrast

most marked with the paranoid


Doubtless here, among other factors, the question of

age comes into play; the more mature the mind, the more the
delusions tend to assume a logical sequence, a logical structure.

Because of the generalized type of hebephrenia,

I believe it

quite proper to speak of


as the simple









derived from



and phren





the very greatest value, because


the fact of the early age of the patient.




by the

fact that to the general

sjonptoms of dementia praecox, already considered, there are



motor phenomena, spasms,



stereotyped postures, automatism, negativism, verbigeration,

Catatonia, according to Pickett's statistical observa-

tions, occurs in a

group somewhat older than the hebephrenics.

In keeping with this


find a well-marked initial








depression and a well-marked


of expansion.


lusions are, as in hebephrenia, unsystematized, unfixed, varying, changeable, disappearing.


and then



paranoid references are met with;

thus, the patient tells us

that people are hearing his thoughts, people are talking about

him, are talking of things he has done, that he


to be punished,


true paranoid structure

however, not


The name

catatonia, like the

word hebephrenia,


an ex-

ceedingly valuable and Avell-chosen one;

derived from







the idea of the distinguishing feature of the affection.



Dementia paranoides, a term


introduced by Kraepelin,

especially applicable to the third


dementia prsecox. dementia prsecox,

It presents the general

symptom group
by the


and, in addition,



fact that the delusions

present distinct evidences of systematization, although this








indeed, the well developed logical

arrangement of paranoia.

The affection is ushered


by a preliminary period of depression,

weakness, general fatigue, headache, and sleeplessness.

soon the patient becomes actively disturbed.


is restless,





him, talking about him, he

in danger,


about to be

threatened with torture,


At the same






be hallucinations of vision and of the other
Delusions of persecution, in part confused



and disordered,

part coordinated and systematized,


dominate the picture.



and delusions



are painful, and the patient clearly and definitely refers his
sufferings to agencies in the external world.

Sometimes ideas
of the patient
his per-

of crime, misdeeds, or transgression

on the part


their appearance,

but they serve only to explain


Similarly, the ideas

sometimes have a hypochonis

driacal basis,

and the patient believes that he


because he has some terrible

some dreadful deformity.

That, in his efforts to escape his persecution, he

may now and

then attempt suicide


not surprising, but

much more

quently the paranoid dement

dangerous to others, sometimes


upon the persons about them

relatives, friends, attendants

—are common occurrences.

After a time, variable in duration, and usually not very long






noted that the patient


ing expansive, and this change

gradually more and more


patient becomes talkative,


himself to be a person of consequence; sometimes claims, as in



that he


not the person he


supposed to be,

that he has suffered substitution in the cradle, that he


noble or of royal birth, that he


very powerful, omniscient, a

great discoverer, a great inventor, or perhaps that he has a

mission to perform, a revelation from the Deity to communicate.

The various

delusions seem to follow without relation

to each other.

Apparently they are based haphazard upon

the hallucinations and upon the misinterpreted sense impressions.


word, a gesture, a fancied resemblance,



to give rise to the

most phantastic

train of ideas.


just because they are varied

and multiple that the delusions
However, as
in the

lack the coordination seen in paranoia.
latter affection, the patient


find in his grandeur

and great-

ness the explanation of his persecution.

Again, as might be

expected, the delusions lack the fixation of paranoia; the trend






of the ideas, however, continues to be the same,
sists ally,


this per-

during the disturbed period of the affection.



rarely, hallucinations

appear to be absent or are

very slightly marked; be evolved from

such cases the delusions appear to

illusions of sense,

from gross misinterpretation

of things seen, heard, or read, just as in certain forms of paranoia.

They do not


from delusions which have their

basis in hallucinations;

they are alike varied and multiple.

In by far the greater munber of cases, however, hallucinations
are present, the auditory, as already indicated, predominating;


visual hallucinations are prominent, the delusions, as

in the case of paranoia, are apt to deal with mystic ideas




course of dementia paranoides
i. e.,


in general terms, like

that of the other forms;

a depressive period, an expansive

period, together with a progressive mental impairment.


with the other forms of dementia prsecox

shown, not only by

course and general symptomatology,

but also by the not infrequent occurrence of catatonic phe-

nomena, such as
porous states.

fixed positions



and even



bears equally close relations to

the paranoias, and occupies, as

were, a median position in

the series of affections comprising the heboid-paranoid group.

may, with

perfect propriety, be spoken of as "heboid para-

It is



to obtain a clear history of the

period of depression in dementia paranoides, probably because

the patient has not been under competent observation, and
also because this period

at times relatively short.

At the

time the patient comes under institution observation, expansive

may have already made their appearance, and the false impression may be gained that the expansive phase is the first


Again, the patient

phase of the attack.


be in a stage of

and persecutory and expansive ideas may both be

present; one group and at times another


be more promiFinally,


course, too,


sometimes quite


the course

at times relatively rapid;




be true of the period of evolution.

this fact

which has

led the French writers to describe the affection under such


as "delires systematises aigus"


"delires systematises

d'emblee" (Magnan), while the Germans have applied to

such expressions as "acute Verriicktheit," "acuter Wahnsinn"

"paranoia acuta"



All of these
in its develop-

expressions imply a

symptom group which, both
is is

ment and


much more

rapid than that seen in para-

noia; indeed, there

a distinct contrast in this respect between

paranoid dementia and paranoia, the course of which
course essentially chronic.
infer that the evolution of
this is


The reader must
paranoid dementia



sudden, for

not the case;



always gradual.



a preliminary period
before the


and depression


symptoms become


as to attract lay





(Verwirrtheit, Amentia,



has at times been misstill

taken for this form of mental disease has
color to the idea of rapidity of onset

further lent








The conception

dementia praecox, which

have endeavored

to outline in the preceding pages,

that of an organism which



beginnings in a germ plasm defective and abnormal and

the subsequent development of which

necessarily imperfect
is in-

and deviate.

This means that the organism as a whole

This fact must be inferred also from the presence of

such evidences of morphologic deviation as are visible to






observation; these merely imply that other and fundamental
deviations are present in the organism throughout.

Such an

organism must present not only abnormalities of


but also abnormalities of function and especially of


olism. Various facts point to anomalies of the internal secretions.

For instance,



not infrequently noted, as already stated,

that the thyroid gland varies in size from the normal; frequently
it is

unusually small, though occasionally enlarged.


have shown (Dercum and


it is

frequently only half the

normal weight, while the adrenals are frequently double the

normal weight.


role that other glands, especially the thy-


play in dementia praecox, has been pointed out by

Sajous; the function of the


in the general

view of the

of the organism attains here a special significance in fact of morphologic arrest

and deviation.

The occurrence

osteomalacia in dementia praecox as noted by Barbo and Haber-

kandl must also be borne
that the entire chain of



It is

extremely probable,





Clinically, our attention is strongly attracted to the sex glands.

There are the anomalies of menstruation, the delayed and imperfect establishment of

puberty on the one hand, or of sexual
Again, there

precocity on the other.
excesses, sexual vagaries,

the history of sexual

and perversions.


relation to the

sex glands


further indicated

by the accentuation



toms often observed during a menstrual epoch and by the
that dementia praecox

now and then



incidence in a

pregnancy or

in repeated pregnancies, or in

a miscarriage, as

though sex-gland exhaustion played a
Kraepelin have

Tsisch, Lomer,


assigned importance to the sex glands.
indicated a disturbance of the internal



secretion of the latter, but
especially illuminating light

remained for Fauser to throw an

upon the

would appear



from Fauser's investigations that
sex gland protein

dementia praecox unchanged
of the sex


abnormal internal secretion


— enters the blood,

and that

in the

subsequent breaking


of this protein,

substances— defensive ferments
cortical tissue

—are formed

which are poisonous to
the destruction, the

and which bring about
Fauser's results have

of the latter.

been confirmed by a large number of other investigators. Whatever the future

may reveal,



no escape from the conclusion
a deranged metabolism, an

that in dementia praecox there


autotoxic state, in which abnormalities of the internal secretions

play a dominant role; that the internal secretions of the sex
glands are especially involved

extremely probable.


prognosis of dementia praecox



be inferred, on

the whole unfavorable.

However, the following


modify sometimes


a slight degree, sometimes in a great degree
First, the patient

the eventual outcome, must be borne in mind.


pass through an attack, with


phases of depression and

expansion and the other attendant mental phenomena, without
presenting at the end of the attack any recognizable mental





the exception,




However, an increasing

clinical experience

has shown

that the cases in which recovery had been believed to have

taken place quite frequently suffer a recurrence of symptoms,

sometimes after a number


months, sometimes after several

and that

after such recurrence the

mental deterioration

usually pronounced.

This truth applies not only to hebe-

phrenia, but to catatonia

and paranoid dementia as



was for a long time thought that the cases of paranoid dementia,
or acute paranoia (delires systematises aigus), as they were
earlier called,

not infrequently terminated in recovery.
this the




view of the French writers, who believed

that a favorable outcome was quite common.

However, the

His condition was so tack that much worse than to during the previous at- commitment an asylum became necessary. became mani- and before long the patient became violently disturbed. he spends his time in in dawdling. His case was relatively mild. that. The "recovery" However. than a year. or. it was found that he was not giving the necessary attention his affairs. finally cease to make their appearance. lucid. as before. One must the above. However. and he was. and conducted himself an apparently normal manner. the aid of competent nurses. it must be added. as in the no exception to the other forms. the entire attack lasting something entirely well. with rest. has demonstrated that rule. that he has though apparently rational and idleness. obstinate. For example. however. not. go too far in such a generalization as Cases are met with in which recurrences are not if observed. in order that the story should be completed. of fest. a terminal period of dementia with some persist- ence of delusions and confusion finally supervenes. harm to himself and others. married. Here he remained for some eighteen months. brought under medical observation. each attended by unmistakable and increasing mental paranoid dementia is deterioration. occurring. to and soon that they were badly neglected. ideas of danger. It was again recognized that he was not well. when he again appeared to have recovered. a young man of nineteen passed through a typical attack of hebephrenia. reads little or none. although ten years have elapsed. that he has never re-entered never taken up any occupation.GROUP III THE HEBOID-PARANOID AFFECTIONS 133 fact of repeated recurrences. of was treated successfully outside less the asylum. Soon persecutory ideas. and physiologic measures. and also headstrong. and in trifling pastimes. is indifferent and inactive. He was in apparently Two years later he entered upon a business enterprise. and. and. business. after the lapse of another year. still exists. .

is Now an adult in the late twenties. the patient passes out of observation. but rarely complete. efficiency. symptoms is later appearing strongly suggest that the patient confirmed paranoid attitude. grossly incompetent in business. without self-restraint. without sense of responsibility. untruthful. passed through a typical and pronounced hebephrenic attack which terminated in recovery. Quite commonly. and indeed the larger loss is number. in so-called cases of recovery. even in the most favorable some evidences of mental deterioration —deterioration of general mental make—are noted. Quite commonly. even when approxilevel. as already stated. the mental of a terminal profound and the final result is one and persistent dementia. It up. and we are limited to the rather unsatisfactory account of friends tives.134 wilful. the boy. or and rela- the case is definitely lost to view. as one of Such a case can hardly be looked Further. MENTAL DISEASES and unreasonable. mating the normal should be looked upon with doubt. cases. is passing into a may recover. Recovery in a case of dementia prsecox. and character- must be confessed that sometimes these are very slight and perhaps non-existent. so that a partial or incomplete recovery results. he unreliable. Mental impairment quite conomonly ordinarily left in a recognizable degree. . a case of dementia prsecox the recovery. is Quite frequently such a supposed recovery of merely a period more or less prolonged remission. In other cases again. a recoverj'- which was incomplete. a lad of fourteen. and given to alcoholic excesses. There may for a long time be some persistence of confusion and delusions and of other mental phenomena. One such case was studied by myself many years ago. It is true that all alienists can recall cases of recoveries without subsequent recurrences. In other words. but finally even these disappear. but is this is certainly the great exception. this impairment is decided. other upon recovery.

found. it may be said that. massage. is not very However. it all depends upon what meant by a Kraepelin himself places the percentage of recoveries with impairment much higher. If the relative mildness or severity of the attack. is The second question that confronts us there any way in which a favorable outcome can be foretold? Unfortunately the answer that can be returned to such a question satisfactory.GROUP Having laid III THE HEBOID-PARANOID AFFECTIONS 135 emphasis upon the unfavorable aspects of the subject. more favorable outlook presented by catatonic first. most frequently with some traces or evidences of is. will often yield surprising results. for instance. so mild. bathing. in addition to the cases. permanent damage. a lesser duration. are. In cases and relatively chronic course the danger of mental de- . some encouragement. simple rest in bed. however. remains that quite a number of cases get well. in catatonia. and. Secondly. the attack be mild. the more favorable the outcome. a lessened danger of of slow permanent change. other things equal. with or full massive feeding. other things equal. and. there is the relative acute- ness of onset and course. that the patient can be cared for outside of an institution. factors of moment. While my own figures is in regard to recoverable cases would place the somewhat re- higher than this. let us now turn our It is attention to such facts as offer first place. however. and other physiologic methods. Cases that pursue an acute and active course presage. in the that cases of catatonia offer a distinctly more favorable outlook than the other forms. any conditions. we have. The practical fact for us. covery. therefore. therefore. the less severe the attack. in hebephrenia experience and about 20 per cent. exercise. his ability to secure detailed and elaborate care. The Under circumstances of the patient. as might have been anticipated. Kraepelin's observations lead him to state that is the percentage of recoveries about 8 per cent.

is neurasthenia. hypochondriasis. e. less promising as re- Finally. a recurrence. prognosis of paranoid dementia Its is deserving of a final i. other things equal. forties are Cases of late hebephrenia and of late duration final out- catatonia offer a relatively unfavorable prognosis. similarly. because gards the outcome. the age of is the patient is important.136 terioration. not rarely a careful study of the patient's early history reveals attacks variously diagnosticated as nervous prostration. In regard both to late hebephrenia and late catatonia. an unfavorable outlook. is especially prolonged is —often many years—and the of come quite commonly that marked and persistent deteri- oration. final re- The word. Third. It cannot be sufficiently emphasized that offer late attacks of dementia prsecox. duration extends over months and years. MENTAL DISEASES by the time the attack is over. the writer is convinced that the attack observed is frequently not the first attack of mental disturbance from which the patient has suffered. a recurrence frank it is and pro- nounced. both as regards duration and covery. a catatonia may not put in an appearance until the late thirties or even reached.. the diagnosis then of a "late" catatonia is made. is. also greater. Relative early age or youth proportionately favorable. but the patient . Un- fortunately attacks of dementia prsecox do not always occur in youth. the periods of depression and expansion may be completed in the course of several months or a year or two. The inference justified that the attack observed is in reality a recurrence. no matter of which form. but. Sometimes a hebephrenia does not life is set in until the third decade of well advanced. I am convinced that an early and perhaps improperly diagnosticated attack of hebephrenia may recur years later as a catatonia. hysteria. lasting often a year or more.

second. or the expansive phase fallacious may even present the appearance of preceding the depressive. and. the marked the tendency to more favorable. months. the more the picture resembles merely less an active confusion. after the first attack another may make its appearance. nor necessarily. Repeated at- tacks are disposed to be of increasing duration. the attack. The more rapid the onset and the more acute the course. it should distinctly unfavorable. imply a subsequent impairment or dementia. as may make is a recovery. there a well-marked several tendency to recurrence. persecutory and expansive ideas may may be commingled. in the recurrences the periods of depression and expansion not be clearly outlined. and the systematization. more frequently years. the presence of is anything suggesting perFi- sistence or fixation of delusions nally. prsecox. the patient. by the must factor of age. just as in the other forms. other things equal. though beginning as paranoid dementia. to a somewhat lesser extent. There can be no doubt that the French observers were correct in regard to recovery from a first attack. As in the other forms of dementia we are governed by the severity and the acuteness of the attack. Two additional and important facts first. also be borne in mind. Finally. other things equal. This is apt to be followed by evidences of deterioration more or less marked.GROUP is III —THE HEBOID-PARANOID AFFECTIONS less 137 left in a condition of persistent and more or marked mental impairment. the shorter. Indeed. may assume a chronic form. or the affection Subsequent attacks emphasize the damage. and probably passing through a series of . in the other forms of dementia prsecox. Unfortunately. Again. the attack does not always. It is the un- fortunate fact of recurrence that militates against persistent and eventual recovery. be repeated that cases are not wanting —cases usually of a subacute course —which. the outlook.

He and regards them merely as more frequently recurring pictures does not ascribe to them a higher clinical value. re- and paranoid dementia are lated to each other. the catatonic. by impairment with depression and may be stupor. secondly. is it hardly necessary to point out that the pictures presented by individual cases of dementia less praecox vary greatly. impairment with depression and delusions. so is the paranoid form related to the re- maining members In conclusion clinical of the heboid-paranoid group. in contrast to the "delires systematises aigus" (paranoid dementia). This transition its infrequent. eighth.138 MENTAL DISEASES and eventuate is recurrences. fifth. Legrain. and the paranoid forms established. the paranoid forms." have described a mental affection which. lin. but has been affirmed by Mendel. and There is here a link of transition between the paranoid form of dementia prsecox and the paranoias. by impairment with it silliness. a form characterized thirdly. an agitated form. under the term "delires systematis^s chron- iques. clinical studies will Detailed it add greatly to our knowledge. catatonia. prefaces the descriptions which he gives by the statement that between the various forms there are so many transitional forms that they cannot be sharply delimited. others. is . seventh. fourth. It but there is no good reason to doubt occurrence. just as hebephrenia. gradually pass into a chronic form as a paranoia hallucinatoria. has been denied by Krafft-Ebing and by Magnan. a periodic form. a circular form. may be considered as PARANOIA French writers. Westphal. catatonia. In other words. sixth. but may be safely stated that the original grouping into the hebephrenic. Schiile. Kraepelin has distinguished no than ten forms. and finally a form characterized especially by confusion of speech. Kraepe- however. thus. a form characterized by simple dementia. ninth.

e. and the later Krafft-Ebing and Schiile. Among the Germans it was Westphal. was here that Mendel rendered a signal service to psychiatry. Falret pere (1864)." It was Mendel who and it first gave to the word a its definite application. Plato. both of them expres- sions based upon erroneous conceptions of the affection. terming the affection delusional insanity. the two folly. Aeschylus. may be men- tioned monomania and partial insanity. It it. Falret fils and others were no less epoch-making than the studies of tonia. displaced. and became synonymous with the delire systematise of the French and the delusional lunacy of the English writers. mind. by systematization Our knowledge of this subject is of gradual growth. logical. unfortunately. by a i. a condition of "lack of freedom of mind with exaggerated obstinacy in conception and judgment. and the original observa- tions of Laseque (1852). It resolves itself into obstinacy. and doubtless by other madness. Later Heinroth (1818) described. they employed the rather ill-defined words "Verriicktheit" and "Wahnsinn" in describing which led subsequently to much confusion. It is now a term now generally accepted as in meaning insanity with systematized delusions and chronic course. It found its way into German literature late in the eighteenth century (1764). Verriicktheit and Wahnsinn. arrangement of the delusive of the delusions. perversity. who differentiated symptom terms complex.. . and is characterized beliefs. roots napa. Kahlbaum and Hecker it in hebephrenia and cata- In England was more particularly Savage who first clearly grasped the subject. Among the older terms. The word paranoia (-apdvota) was used by Aristotle.GROUP III —THE HEBOID-PARANOID AFFECTIONS 139 of slow evolution. quickly replaced predecessors. under the term paranoia. runs a chronic course. Morel (1860). an orderly. beyond. in the sense of derangement. when Vogel applied it rather indefinitely to what was apparently melancholia and mania. (1878). writers. and voo'?.

I^ater he placed this phantastic form under the caption of dementia prsecox. the second. speaking. between and the so-called non-hallucinatory form. howfirst. The various forms can. a which the delusions are evolved independently of or in the absence of hallucinations. he again Later still. in the eighth edition of his Psychiatry. Kraepelin at first. The in which the delusive beliefs apparently arose independently of hallucinations and seemed to be formed by the combination of actual sense impressions. delusional lunacy or paranoia As may be fests itself in mani- a number of ways.140 MENTAL DISEASES anticipated. being best characterized as the "hallucinatory" form. the affection should unhesitatingly be included under the general caption of paranoia. removed gave it it it from under the caption of dementia prsecox and an independent position in his nosology." Unfortunately. In the opinion of the writer. He now gave the name "paraphrenia. There has been a tendency for some years past. para- phrenia has exactly the same meaning as paranoia and suffers the further disadvantage of being an artificially made word. be conveniently in grouped under two heads: a form which the delusions are intimately associated with hallucinaform in tions. second. however. and the writer believes that alienists would do well to retain the word paranoia in the original signification in which Mendel . paranoia resolves itself into Roughly a hallucinatory and a non-hallucinatory form. he termed the "phantastic" form. the underlying features are always the same. While individual cases vary. now calling it a "second" form of paranoid dementia. he termed the "combinatorische" form. it Further. in which the delusions apparently arose in association with hallucinations. and. following the lead of Kraepehn. as will become apparent later. ever. above forms. there are close relationships. to greatly restrict the use of the word paranoia. first Under the general caption embraced both of the of paranoia.

the patient remains in the period of depression often spoken of as the period of persecution —during the entire time that he is under observation. in many cases." The subsequent period is of expansion. Finally. is a transition to an ex- pansive period. third. practically a life-long disease. there is. but this period. the non-hallucinatory form. Finally. its delusions thej' have a clearly marked logical struc- are logically is arranged and coordinated. these remissions giving recurrences. gradual. in some cases. there an period of depression. the dementing change progresses in others. instead of extending over a number of months only or perhaps a year or over so. first. It stands for a definite thing. finds its full expression. In general terms. namely.— GROUP first III —THE HEBOID-PARANOID AFFECTIONS 141 employed it. more especially of the hallucinatory form. cases. the expansive period never being reached. steadily Again. already pointed out in the beginning of this chapter in regard to the role of heredity. its progress is attended by In some a gradual deterioration. the deterioration often takes place with exceeding slowness.. and course. as might be expected. by remissions or partial remissions of symptoms. also of many years' duration. Hereditary factors are here the order of . an increasing dementia. As before. ture. like the period of depression. e. paranoia differs from the other members of the group thus far considered. second. The transition for the most part. Paranoia is. the progress may be interrupted. i. is the affection it is of exceedingly slow evolution of adult life. like the other members of this group of affections. now extends many is years. though rarely. therefore. especially in and even obviously rapidly. and often spoken of as "the transformation of the per- sonality. as follows: are systematized. system- atized delusional lunacy. just as in the other way later to members of the heboid-paranoid group. In paranoia the general truth. initial an affection As before.

however. and aberrant childhood justify the and youth view that the tendency to the later onin adult life is coming paranoid degeneration in the individual at his birth. as they pass through the period of it ive. has deviated of structure from the normal. sometimes or presents oxycephalic. shy. Frequently patients who subsequently develop paranoia betray quiet and reserved. dif- fident. already in their childhood and youth striking peculiarities of conduct. or of masculine characteristics in female patients. in a more marked degree they keep . taciturn. to That the patient has had transmitted him or is the victim of a defective and aberrant organization may also be evidenced by the presence of gross morphologic arrests in paranoiacs and deviations. . perhaps in the presence of feminine characteristics in male patients. they reveal the same characters and. and They remain apart from do not mix in the play of other children.. may be. perhaps in relative development. with suggestive Such morphologic features occur frequency. introspectLater. some other abnormal It may be that the trunk. self-conscious.142 MENTAL DISEASES is the day. They may be unduly suspicious. heredity. Gross anomalies of structure. egotistic. When a history is possible. Sometimes the it is skull presents a markedly flattened occiput. and even when gross anomalies are not evident this inference may be justified on other grounds. at least always occupied with themselves. a patient and detailed inquiry usually reveals significant facts. youth. abnormally their comrades. At any rate the facts of morphologic peculiarities. Often they are morbidly sensitive. form few attachments. have no friends. the Umbs. and 85 or 90 per cent. That a history of a morbid childhood and youth cannot be obtained in every case need hardly be stated. or the digits reveal peculiarities. to themselves. already present it is In keeping with this idea. of course. strikingly asymmetric. are distant. as a whole. trait. probably a moderate estimate. proud. justify the inference that the organism.

GROUP III —THE HEBOID-PARANOID AFFECTIONS is 143 significant that paranoia somewhat more frequent in persons born out of wedlock. non-halluciwill natory form. play a role in the etiology. e. is Finally. Paranoia occurs in many forms. It is sometimes said that great disappointments. needs hardly Again. the very fact of the bastard's anomalous position favors the attitude of mind so frequently seen in the early lives of paranoid subjects. and. paranoia somewhat more frequent among the unmarried. wounded pride. i. among those lives differ whose from the rest of the community in that they are denied the fulfilment of function resulting from marriage and parenthood.. and the fact of living alone favors the evolution of the paranoid view of life. unhappy marriage. There can be no doubt. who lead irregular sexual lives among the defectives. the common now hallucinatory It is form. Evidently such a role must be subsidiary to the one great factor of the paranoid predisposition. second. however. — The common or hallucinatory itself in form of paranoia. as already pointed out. though presenting a variety of ways. neglect. reverses. and. to the hallucinatory form that we turn our attention. That public women and prostitutes generally are in large percentage sub- normal. probably because women bearing bas- tards are hkely themselves to be degenerate. in the lives of those who in those in whose nervous make-up the is degeneration leading to the future paranoia inherent. The traits of the paranoid subject are such as frequently not to favor marriage. merits the following general description: Because of the ex- . that both bastardy and celi- bacy are factors of moment only are predisposed. these can be roughly grouped under two heads: the first. and that many others are likewise to be classed to be pointed out. PARANOIA HALLUCINATORIA Symptomatology and Course.

unpleasant. palpitation. perhaps suspicious and un- upon a period of depression and of hypochon- He begins to suffer from various obscure visceral sensations. he apt to re- press the impulse to complain until his sufferings sistent. enters driasis. . it may be. Words. gestures alike. distress in the prgecordia. There are fulness or emptiness of the head. to believe that his sufferings have been imposed on him from without. the genitals. talk about him as he passes. that for for is said. Later they may be more insistent. whisper about him. tone of voice. faint. unpleasant. him. and distressing. throbbing or other queer feelings in the clearly hallucinatory. sociable. The simplest facts acquire a special significance. the body. threaten him with harm. painful. These sensations are of the visceral and belong to the group hallucinations. they may be vague. genitals. or. Everything everything that is is done. sensations of pressure or constriction. or strange sensations in the stomach or bowels. become in- Sooner or later he begins to seek an explanation of his Sooner or later he comes troubles in causes external to himself. Everything that he hears or sees begins to have some relation with himself. However. has a special significance him. everything interpreted by him as being intended People dislike him. The patient refers them to the head. headache.144 MENTAL DISEASES it is tremely gradual appearance of the symptoms to fix impossible more than approximately the period of onset. regard him with aversion. an individual who has previously attracted attention as being odd and eccentric. reticent. Everything about him is changed. and the general somatic suffers The patient apparently from these hallucinations for a long time before he speaks is of them. Morbidly reserved and suspicious. People look at him. or only occasional in occurrence. or who has been observed to be morbidly reserved. the most natural happenings have a sinister meaning. buzzing in the ears. and peculiar. These appear at first to be but slightly pronounced.

kill him. usually of vile.GROUP III —THE HEBOID-PARANOID AFFECTIONS Little 145 are inimical and insulting. roaring. to the ceiling. though these sounds may. The sented hallucinations of hearing. at least. to the walls. clinical observa- show that the sounds as first heard are frequently described by the patient humming. obscene names. Hallucina- On the other hand. or are compared to the ringing of bells. when they begin Doubtless in some cases they begin early and account for the buzzing and other distressing sensations of which patients in the early stage of the disease complain. of life. home and tation If is daily furnish convincing proof that his interpre- correct. of curses. auditory hallucinations are the most prominent. to the open window. by little the patient comes to the conclusion that he has long been an object of animosity. Sometimes short phrases are "kill heard and these constantly repeated: "serves him right. The most trivial events of the past. sometimes they are described as strange one patient described them as his delusions. like the other symptoms Just pre- by it is paranoia. will be found that special sense hallucinations have also made their appearance. tions However. profane. of childhood and school. of course difficult to say. reproaches. tions of vision are relatively rare. at times be explained as ordinary tinnitus. noises or as sudden explosions. That the patient refers these sounds to the street. and the case with hallucinations referred to the general body surface and to the genitals. are of gradual evolution." him right. pistol shots and interwove them with In the well-developed period of the affection the auditory hallucinations assume the form of words. In the great majority of cases they are of hearing. it is true. it the patient be studied at this time. halluthis is also cinations of smell and taste are not infrequent." Sometimes in this con- . threats. buzzing. serves 10 him. is but natural.

and everything they directed against them. At first the patient has a vague and general idea that are caused his sufferings. may be the relatives. that everywhere there are telephones. threats from his enemies. to poison. that the telegraph wires which pass his window convey to his room it taunts.146 dition illusions of MENTAL DISEASES sound play a vivid role. the police. systematized. or it may be that he clearly distinguishes the voices of several persons whom he knows. The delusions are. or it may be a special organization. more vivid. Later. to him. Quite commonly the delusions assume specific and detailed features. wall. that it is filled with speaking tubes." are annoying him. religious or social. That under these circumstances delusions also are present need hardly be pointed out. the government. "they. the business associates. and well coordinated. Thus the patient believes that there are holes in the through which his enemies hurl insults and curses. the servants. in some cases early. or nowadays wireless. vile names. by others. believes that the house is Quite frequently he wired. or the rattle of a wagon constitute a recurring tirade of curses revilings. a certain group it of persons selected as constituting the conspiracy. and which recur in various patients with great fre- quency." "people. or Sometimes the conspiracy see or hear is includes everybody. his torments. At other times The hallucinations . the use. more complicated. "they" have conspired to injure. well arranged. electricity. is it electrify. or through which they throw poisonous or foul-smelling vapors or gases or other harmful substances. thus. as has already been pointed out in the general consideration of the subject. The patient may recognize the voice of a special person. Gradually a notion of conspiracy evolved. his tortures. as when the and ticking of a clock. They are logical. may be the phonograph of which his enemies make may become more detailed. the neighbors. is persecuting him. or. to kill may be. the foot-falls of a passing stranger.

may be the genital hallucinations. that the patient may a different set of hallucinations to each ear respectively. are notions of in the beginning vague. and are apt to be among the most important factors determining the con- duct of the patient. and he of articulation. pierced. Delusions of poisoning are exceedingly common. their genitals torn by instruments. . as in the act though not uttering any sounds. his bowels dragged and twisted. horrible stenches. wall. under such circumstances. and are the work of his enemies. tortured. may even move his lips or tongue. It may be. cramps. his tongue the seat of tastes his strange. At That other times the patient refers the voices to his stomach. castrated. lieves that some one other than himself is mouth. wrenched. is and that he believes food and his drink to be poisoned but a natural sequence. his teeth. his head. flesh is pinched. These come to him through holes in the all is through the door. acquire notions of double personality. sodomized. burns. to hypochondriacal ideas. can be readily understood. Women are outraged. become gradually better defined and acquire a more distinctly objective character. vile. the window. spasms. or to some other part of his body. to his head. painfully abused. and give rise merely to illness. torn. as we have seen. At the same time. he may. or of his body being "possessed" by some one other Sometimes he betalking through his than himself. his The patient feels touches.GROUP III —THE HEBOID-PARANOID AFFECTIONS 147 the hallucinations appear as an echo of the patient's own refer thoughts. and horrible. blows. Men are mas- Hallucinations of smell and taste also occur with great fre- quency. foul vapors. Especially noteworthy. his eyes. seared. The patient smells disagreeable odors. to his throat. General somatic and visceral hallucinations which. turbated. electrified. too. disgusting. too. the latter are repeated aloud into his ears as fast as they are formed. have intercourse night and day.

" was a female figure robed and whenever appeared he became greatly in great danger. The patient. and it is not impossible that the visual hallucination was displaced or overwhelmed by the powerful impression made upon the sense of smell. but with particles of meat. saying. or may it decline to answer questions altogether. when the the "Opaluma" appeared. However. lacks and is inhil^ition. and are then like the other hallucinations painful distressing. short in his replies. press it to his nostrils.148 MENTAL DISEASES Hallucinations of vision during the persecutory period of ordinary paranoia are rare. he would quickly and take repeated Suddenly he would look up and say. sometimes a series of in the case just cited. they may and occur. The patient misshapen may have terrifying visions. He as before suspicious. too. deep inspirations. excited and believed himself to be Careful investigation revealed that the vision relative was that of a female who frequently wore a pink dress and upon as being the source of all his suffering. fixed The delusions become with time and unchanging. she doesn't like that! The bottle was certainly very vile and foul-smelling. the origin of which often is cannot be traced. as word. is impulsive. frightful mien and threatening gesture. a man of some education and an artist. This symptom but a part of the general tendency to degeneration and self-control fixation. Sometimes the patient adopts. figures or men and women of Sometimes of it is he may see gross. One my patients. especially his persecutor whom he sees. a new words. "You know . hallucination." in "opalescence. and quick to take offence. He carried with him a bottle containing some putre- fying organic matter —apparently a decomposing broth or soup He kept it tightly corked. She's gone!" uncork the bottle. had a frequently recurring visual hallucination It it which he called the "Opaluma. whom he had centered In order to rid himself of the dreadful presence he adopted a novel expedient. "Ah.

to the dence. complain to those about him. That may under these circumstances become exceedingly danger- ous cannot be sufficiently emphasized. mayor. to the conclusion that there it is Usually he comes nothing else to do . hearing a sudden sound behind him. may believe himself to be and may turn and strike a blow. Not infrequently he changes his resi- moves from place to place in the vain attempt to escape from his persecutors. not only will terminate his sufferings. frowning and gesticulating. when the patient has settled upon some one person or persons as constituting his enemies. He buys a revolver. and lies in wait for his victim. the patient usually makes preparation for the act which he believes will right his wrongs. Not he infrequently he takes the law into his own hands. His letters. insulted A paranoiac patient. is most The danger. patient is now in the full tide of his persecution. this is not the chief source of danger. At other times he seen talking to himself. The victim being selected. his complaints have met with no must end response. The may. his friends write letters to the authorities. However. or secures some other weapon. and origin to be feared. is too. that he is is the cause. when he has selected some one individual who of his troubles. but his act will call the attention of the authorities to his plight. He in his extremity." he seems to take for granted that the voices he hears so plainly are also heard is by his questioner. the greater because the unfortunate victim usually in igno- rance of that which may befall him. perhaps with jeers and laughter. He may police. to the or neighbors. One paranoiac rings . mainspring. The criminal records of every city unfortunately furnish repeated instances of assault and murder on the part of delusional lunatics. or the hallucination may It is give rise to an aggressive impulse. Sometimes he appeals to the courts.GROUP III —THE HEBOID-PARANOID AFFECTIONS 149 already. so that a stranger may be assaulted. and he it all.

authorities. the people on the street talk about him. with no attempt at flight or concealit is ment. more Little frequently for several years. attention to his. by little. a third waits until he catches his his tea. though sometimes rapidly. overt. the ideas of persecution are replaced by ideas of expansion and the patient undergoes a veritable transformation of the personality. when certain changes are observed both in the delusions and in the demeanor of the patient. Usually when the act over he makes no at- tempt to escape. and that quite frequently performed in a dramatic call manner. tells all it. about the murder. suffer- The persecutory phase continues for many months. as though to ings. the causes that led to justified it. . another studies the traps seeking coming movements of his victim. great organizations. cunning. be stated as a general truth that the act is open. usually a revolver. poisoning rare. Quite frequently he gives himself up to the tells all and at once about his troubles. Later conspiracies are formed against him. much less frequently by cutting instruments is or other means of assault. the patient's. murder is experience of the writer. indeed. enemy in the act of spreading the story of shame or catches his wife in the act of putting poison in his in the medicolegal Most commonly. foresight. the newspapers Everybody concerns himself about the write about him. all is Premeditation. the committed by a firearm. the same original is true also of arson. may be exhibited by the patient. and the facts that It may. In the very beginning of the persecutory phase we note that we have to deal with a personality pathologically expanded. That a paranoiac may devise of killing is and unexpected means of course a possibility. patient. and him at his office or place of occupation.150 MENTAL DISEASES is the door-bell and insists upon the person he to the door.

indeed. In reality he rich and powerful. titles follow and adulation. was substituted an he is really of a princely line. The expansive delusions based upon them com- monly lack the definiteness and precision of the delusions of the stage of persecution. he in the cradle. the patient of respect. There can be no doubt that in some patients the transition to the expansive phase is accompanied by this logical train of ideas. the de- tectives. of royal descent. in the form of paranoia we are considering —that the is hallucinatory form —the transformation of the personality more frequently associated with the appearance and expansive hallucinations. at times one and at times the other set predominating. and during this period both persecutory and expansive hallucinations may exist together. of pleasurable vile Instead of curses. praise. the police. combine against him. ever. but is he rank and birth. and obscene names." woman patient who tells us that or of the man who insists that he is is "king. heir to a throne wrongfully deprived of his rights. he not the child of the persons supposed to be his parents. It is not surprising that in the course of the affection the patient should finally arrive at the logical conclusion that he must really be a person of great consequence to be the ol^ject of such great and insistent effort is to effect his destruction. he is is not the poor clerk or really of aristocratic workman he is given out to be. and content to wear his paper crown. . is In some patients the transition to the expansive phase very gradual. wealth. now hears himself addressed in words nobility. they frequently betray by their very content the deterioration attending the progress of the disease. powerful bodies of men. Howis." but goes no farther.GROUP like III —THE HEBOID-PARANOID AFFECTIONS 151 the Masons. as in the case of the she is "queen of the navy. in their turn.

doing so intentionally. self-accusation. evolve a series of systematized persecutory delusions. he attributes baneful results to this or that course of living. He restricts his to one then to another kind of foods. Sometimes he develops ideas of being poisoned. sometimes in regard to a group of persons. sometimes in regard to one per- son. however. it is some other person is to whom he attributes his illness. as has already been indicated. unpleasant. which he refers to various parts of his It is early body or to the different viscera. frequently departed from. tressing. tients Not only are there pa- who during the entire period in which they are under observation remain in the persecutory phase —never reaching the period of transformation and expansion— so there are others who remain. Again. indeed. the temperature. or painful. thinks that the physicians are harming him. these he believes influence his troubles or perhaps make them kind. or later becomes evident. in the preliminary stage of hypo- chondriasis. ideas of the patient may manifest. He watches the wind. and he may. finally. In such instances. as in ordinary paranoia. some one who hostile to him. the paranoid character of the symptoms sooner suffers. as in paranoia ordinarily. to this or that kind of medicine. changes to another. The patient dis- as before. the dampness. as it were. noted that he pays great attention to the passing conditions and happenings in the external world. hypochondriacal ideas domi- nate the clinical picture. or diet first the rain. He fails to get relief from a physician whom he Perhaps consults. and. worse. cases of paranoia are THE SELF-ACCUSATORY FORM met with in which among other ideas. and the latter may resemble an ordi- nary hypochondriasis. from obscure sensations. .152 MENTAL DISEASES THE HYPOCHONDRIACAL FORM The picture of paranoia outlined above is.

as they bear some resemblance to melancholia. as in ordinary paranoia. he says that he not responsible for the things that he is has done. as already stated. indeed. or may. nor does he evolve the delusion of the unpardonable sin. while the patient is is under observation. General somatic and auditory hallu- cinations. infrequent. that just be- cause of his prominence he has been selected as the victim of the conspirators. that. He deserving of punishment. and little httle the ideas of self- accusation disappear and are replaced by ideas of persecution. the victim of his evil enemies. an expansive phase may follow. is very wicked. creature. he does not. Everyhis thing convinces him that he has always been —indeed. Besides. times. a thread of persecution may run con- currently with the ideas of self-accusation. the refuse of society.GROUP III —THE HEBOID-PARANOID AFFECTIONS 153 These cases are infrequent. that he was led to do them. On the contrary. he the victim of a conspiracy which has brought about the situation in which he finds himself. The patient may a vile say that he evil deed. talk of the shame and ruin he has brought on his family. and yet finds the punishment to is which he being subjected out of is all proportion to his faults. He by resents the injustice from which he has suffered. that he has committed this or that is has been dishonest. and pre- vented him from doing anything good. again. the patient believing that the attention which has been directed to him from all sides is due solely to his importance. Paranoia with auto-accusations if is. and in due course. may also play a role. become frankly established. the picture presented may varj'- at different Auto-accusatory and perse- . has committed theft. the scum of humanity. who drove him into ways. in How- ever. not rare. from who always very birth —the subject of evil influences. Later still. Again. the very extent of his self-accusation implies a certain expansion of his personality. but may lead to confusion. as melancholia.

attribute The patient may as before them in due com-se to persecutory agencies. THE MYSTIC FORM Much more interesting than either the hypochondriacal or is self-accusatory forms of paranoia the form to which the term mystic paranoia has been applied. are born. the abnor- mal tendencies of the child in may become greatly exaggerated. characterized by vague and bizarre sensations. made up the subject of undue or be brought in an atmosphere too austere and repressed. thus. have been It is or. noted that patients who develop mystic paranoia frequently present in their childhood abnormal religious tendencies. passes through Here the patient again a hypochondriacal period. that is. now the one and then the other group being more prominent. we must bear mind that paranoiacs made. enhances and hastens . if a child presenting such peculiarities be in addition religious training. also. that his sufferings inflicted upon him in accordance with the divine will.154 cutory ideas MENTAL DISEASES may be present at the same time. the patient believes himself either to be the victim of evil spirits. not suffer it. perhaps. make premature that or precocious religious profession or manifest phases of religious exaltation. demoniac or diabolical agencies. an atmosphere in which the depressing features of religious doctrines are over-emphasized. and that the delusional lunacy from which they does not require an improper religious training to develop the latter merely. However. in suitable instances. It can readily be understood. or the autoaccusatory may finally give is way altogether to the persecutory ideas while the patient under observation. as just indicated above. but sooner or later they receive a mystic interpretation. devote themselves with abnormal fervor to their religious duties. they dwell upon and discuss religious questions to a morbid degree.

sorcerers. As has just been stated. it characteristic of mystic paranoia that visual hallucinations. Sooner or later visual hallucinations are added. spends his more and more intense time almost continuously in religious contemplation and prayer. like the sexual hallucinations. the Saviour. Every sexual act is predis- ceded by painful struggles and followed by remorse and couragement. He One is being persecuted by evil is spirits. in love with this or that saint.GROUP III —THE HEBOID-PARANOID AFFECTIONS In 155 the development of the sjonptoms. are pregnant. sexual excitement marked. and finally begins to hold communication with God. of the remarkable facts of mystic paranoia the great frequency and prominence of sexual phenomena. who appear to him in visions. Sometimes the patient's eroticism is is purely mystic. the visceral and general somatic hallucinations of the depressive period are ascribed by the patient not to the persons about him. are very frequent and prominent. or they claim intercourse will give birth to the Saviour. their These doubtless have birth in genital hallucinations. perhaps sexual perversion. with the Deity. of all the visceral hallucinations these lead to the results. The hallu- . The patient who is absorbed in his excessive piety becomes in his devotion. the Virgin. this or that Women are subjected to carnal temptation by the Godhead to test their virtue. state observed in the period of full development many cases the delusional may properly be looked upon as merely an outgrowth or amplification of the abnormal traits inherent in the child. sexual excess. or he may believe that he being pun- ished is by God. the angels. by by the devil. and The sexual hallucinations seem in some cases to be very vivid and to be accompanied by very active sensations. most is striking The patient is erotic. but to mysterious and occult causes. practices sexual congress. he gives way to masturbation. is Indeed. he or she divine personage.

as upon his period of depression. he a man or woman . and a period of expansion. in many evident that the visions also speak to him. he is he destined to be the Messiah. to earth. the great future that to save the world. however. suffering from the evil inis fluences about him. Quite commonly the mental state of the mystic paranoiac is such that his pathologic condition is is readily recognized. tions subjected to carnal and other tempta- by the devil. the patient hysterical crisis. and Thus. he is. tested. glorious and imposing tures.156 cinations MENTAL DISEASES may consist of bright lights. to reform mankind. figures. actually engaged in carrying out the divine will. later. the ideas evolved gradually and slowly systematized. prepared for the great role to The period are of depression is commonly quite prolonged. as in the other forms. of powerful per- Sometimes. In mystic paranoia. a transformation. during which he follow. may pass into a clearly He may pass into a condition of ecfixed and not infrequently he assumes or cataleptic attitudes. brilliant halos. notwithstanding. with its trials is a period of probation. chastened. who smile upon him. The and patient looks sufferings. The expansion grows is he not infrequently asserts that he "the Christ" or God himself come back marked stasy. tells make signs and ges- Usually the patient cases. is tell is him of the great mission. is Sometimes the transition to the expansive stage so that both persecutory very gradual. In other words. and expansive ideas may be present at the same time. During the seeing of the apparition and the hearing of the voices. it is us of the things he sees. and the voices is his. in the progressive development of symptoms hallucinations of hearing are added. until to represent God on earth. while the patient believes himself is to be ordained. the patient passes through a period of depression.

Mystic paranoia a danger that is real. a period often regarded by them as one of penance. The unknown. Realities are hallucinated away and replaced by the intangible figments of mental disease. so arising The communicated madness may become epidemic and may noiac last for centuries. slay his own child its — perhaps as a ing or in order to hasten advent into paradise. insidious. Under circumstances. and even by Gentiles. are denied and absurd delusions substituted. will scourge themselves . Mystic paranoiacs are not physically as dangerous as the ordinary persecutory cases. a typical mystic. of existence. that portions. so dramatically told by Zangwill in his ''Dreamers of the Ghetto. the after the collapse of his pretensions "Dormeh" of Salonica.GROUP sonality. also the mys- terious. they weave a chain in hypnotic spell. they bind in hopeless impotence. in obedience to his halsacrificial offer- lucinations. Now and then a mystic will. III —THE such HEBOID-PARANOID AFFECTIONS eloquence. nor speak of those actually found new faiths and creeds. is The r61e played by the mystic para- well illustrated by the history of Sabbatai Sebi. grave." Sabbatai. may grow One need hardly mention the and in divine healers who who is arise in every age every country. long survived him. the occult inspire awe and dread. Others during the period of depression and suffering. blind fascination the simplest workings of the mind. both in Palestine and Europe. and yet their delusions some- times lead them to the performance of barbarous and cruel acts. passed through a ty]3ical transfor- mation. and one. was accepted by many and thousands of Jews. He performed miracles. The every-day facts of life. after a long preliminary period of depression and preparation. and even his death a sect. he infrequently to huge pro- secures a following. too. 157 of force. of natural and not of convincing manner. and finally announced himself as the Messiah.

The method selected may be extremely barbarous and revolting. of a religious sect of their known under the leadership of one number. Only a few years dis- ago an incident occurred in Canada that was almost as tressing and certainly composed infinitely pathetic. The patient beheves that these punishments chasten him and are pleasing to God.158 MENTAL DISEASES or subject their bodies to self-inflicted torture. and a number of persons to die together and longer ago than 1897 an incident of this kind occurred at Ternovo. and that all their sufferings would be at an end. and to arrest force. faint Thej'' and famishing. barefooted and Christ in the wilderness. and by one of their fanatics. thus. seeking that Christ was there. Russia. Others again see in will death. Thus. the Skoptzi. a proceeding which they regarded as sacrilegious. for he lacked the courage to kill himself. hear His voice. while one of their this duty. filled the graves number. in suicide. his own body. they decided to die. and aimless pilgrimage by It must not be imagined that . the patients may bury or immure themselves alive. Not persuade others to join him. and way. led rather than submit to this persecution. who had been charged with with earth and stones. castrate themselves and amputate the breasts their women. he often regards them as Sometimes he mutilates sect of of his only means of sal- vation. The Canadian Govthis cruel ernment was finally obUged to intervene. the only hope Sometimes a mystic may agree may actually carry out their project. a mystic Russia. ice colony. which they entered alive. knew that they would see Him in the flesh. They dug their own graves. bleeding. The member who who carried to fulfilment this terrible act. wandered over and snow. in this its Twenty-five persons actually perished survived. A community of "old believers" objected to the taking of the census. failed to keep his own promise. Members of a Russian as the Doukhobors.

though it is more likely to occur in the non-hallucinatory form. as that it we have seen. of persons It is these who are morbidly vulnerable to suggestion. of hysterical make-up. with is its boasted enlighten- ment and a child of diphtheria. also. Chapter IV. It is own In Salem witchcraft to our meet with incidents equally terrible.GROUP III —THE HEBOID-PARANOID AFFECTIONS 159 incidents of this kind occur only among Russian peasants. little later. a own day. interesting to note. a disease to woman man to all allowed to die in childbirth. nor must we go back to the Middle Ages or to European coun- tries to find examples of the baneful influences of mystic paranot necessary to go back even as far as our noia. Unfortunately every community. and especially large the modern community. own country. This communicated madness be considered a present. contains numbers of persons of feeble mental resistance. this communicated may also. and It is it is they who in turn transmit them to others. that the hallucinations of vision and hearing are excited in a relatively small number. PARANOIA SIMPLEX The term paranoia simplex is here used to designate a sys- tematized delusional lunacy. It is one of the unfortunate peculiarities of mystic paranoia frequently and very readily spreads.) At we will turn our attention to the non-hallucinatory form of paranoia or paranoia simplex. upon whom the delusions are grafted. in our civilization. in which the delusions are related . a contagious become epidemic. be Ordinary persecutory paranoia to others. though rarely. to other persons. because the relatives and friends of the patient are followers of a cult which denies the very existence of disease. may occur in will hallucinatory paranoia. (See Part II. lose his eyesight. it is the naked delusions that are taken up by the masses.

of the ordinary sequence of thought. of ordinary conduct and will- power. in which he treated it as in close connection with ordinary hallucinatory paranoia. suffering merely or However. done violence He has accepted merely differences of degree . beheve. that the patient not even principally from a defect of I his logical faculty becomes evident. from his earlier position. He weaves and sees. the distinguished to clinical fact. departing. systematized and fixed delusions. justly that the difference is between this and the first ordinary hallucinatory form not as great as would at However. think. be regarded as hallu- These disturbances should. with disturbances of his general I somatic feelings or sensations. this form presents certain striking series of although the patient evolves a is. much as special sense or visceral hallucina- Further. e. though the tendency as in ordinary paranoia toward mental deterioration. the course of the disease is is excessively slow so slow that. was such considerations as these which led Kraepelin to grant this affection an entirely separate. his delusions things he actually hears less Hallucinations are here prominent and play a less striking role than in ordinary is hallucinatory paranoia.. peculiarities. second. when we learn that in some cases frank and outspoken hallucinations of the special senses are also present. i. just as tions. In taking this course German alienist has. there at the same time. we conclude sight appear. ciated with disturbances in the even though not the out- growth of special sense hallucinations. I beUeve. We soon learn that the delusive ideas. in this respect. such deterioration may not be marked even after the patient has been under observation for It many years. consideration in his nosology. a remarkably high preservation of the general lucidity. cinatory. a distinct. first. when we carefully study him.— 160 MENTAL DISEASES any hallucinafrom the to the perceptions of the patient rather than to tions which he may have. are intimately asso- way the patient feels.

brooded over and misinterpreted. After all. by obscure bodily visceral sensations. A smile. EveryArticles thing that he sees or hears in the daily paper. the whistling of a . for months. is Sooner or later the patient acquires the notion that he not being properly treated by his family. ill. The depression may be suffi- ciently marked it is to attract the attention of the family. recurring. a harmless remark taken up. isolated himself relatives. that the purposes of psychiatry and student are best served by retaining the word in the sense in which Mendel first employed it. which ills. more fre- quently fugitive. and at once attributed to their desire for his death that they might profit by his estate. actors 11 now adds fuel to the flame. Little is indifferent. while in this stage. no one appreciates him. and denied himself alike to friends and latter The fact became alarmed and declared that he must be a which he indignantly denied. may be slight in character. by little his distrust of those about is him steadily increases. unnatural. changing. It is by depression. He develops a growing feehng of antagonism to those about him. being ignored. The beginning characterized of the affection is extremely gradual.GROUP III —THE HEBOID-PARANOID AFFECTIONS 161 inter- as radical distinctions. and has not given due weight to mediate forms. of the as already stated. a covert sign. the existence of which must be frankly admitted. the discussion resolves itself into the question of the use and appHcation of the word paranoia. a phrase. conducts himself like a stranger. and to me it seems. is He feels that he is is not receiving the attention which his due. retreated to his home in the country. even inimical. A word. by vaguely defined hypochondriacal or latter attain the character At times the of well-defined hallucinations. no one understands. perhaps accompanied by ill-defined fears or suspicions. upon the stage. a glance. a cough is regarded as an expression of derision or of hatred. One of my patients.

may include even the crowned time. At he may later accuse persons about him of wilfully and purposely maligning and trying to ruin him. Sooner or later he becomes convinced of the formation of a conspiracy against him. self. vilified. Sometimes this conspiracy as- sumes huge proportions. calumniated. now denies his The reputed parents are not his. they suddenly stop speaking when he enters the room. very learned. He looks upon their astonishment as assumed.) The same believed that a huge conspiracy had been formed him to obtain possession of his wealth. patient against (See Part III. grandeur. is on the eve of making great discoveries which he of will with great magnanimity give to the world. another still dis- covered that his right hand communicated to him in auto- matic writing the manner in which he was to conduct his business with success. he develops ideas of qualities in At the same He discovers is new and wonderful him- he feels that he very talented. One num- the patients under my of observation boasted of having large written many hundreds poems and exhibited a ber of doggerel rhymes. libeled. a great composer. traduced. a great poet. and upon their disclaimers as mere evasions of the truth. To accentuate the difference between himself . They have and merely been the paid agents of his enemies to keep him in obscurity. first reticent. look guilty when he addresses them. As in ordinary paranoia. are frightened. he parentage. with the circumstances in which he has been born. is all are intended for him. He being lied about. Long dissatisfied with his surroundings.162 popular air MENTAL DISEASES upon the street. and heads of the world. or speak in whispers. Chapter I. Another made a great mathematical —namely. the very magnitude of the conis spiracy against the patient proves that he in reality a great personage. discovery. all have a peculiar significance. that numbers have sex.

merchants. it is How- rather his manner. but frequently persist in a marked degree. is however. Mes- has a mission to perform. his demeanor. her her neighbors. the editors of news- . if only to pass him in their carriages. as did one patient. siah. Further. The patients suffering from this form of paranoia commonly ideas. after all. the spelHng of name. men to of affairs. sister. The fact that the patient is is really an important and powerful personage strengthened by the evidence which he sees everyDistinguished people. the expansive ideas are the depressive. royalty. he is a great reformer. is to become Pope.GROUP his family. and there not that definite period of the trans- formation of the personality so often seen in typical hallucinatory paranoia. may believe himself to be the He may also dress himself in some peculiar way in keep- ing with his expansive state. deliberately changed both her name and her mother. prominent citizens of her city. in one patient. princes. when the patient is well launched into the expansive phase the persecutory ideas are usually not forgotten. The expansion times assumes almost incredible proportions. relatively is present a depression. the nobility. Thus. His hair or his beard in their cut. another added a new name to the one she already Another still bore and changed her nationality. present a commingling of persecutory and expansive In the beginning there phase. go out of their way meet him. people of wealth. a woman. or. however. may be worn excessively long or may be peculiar ever. much more pronounced than at the latter seem merely to stimulate and ac- centuate the expansion. and gestures that attract attention. He fancies that great riches await him. where about him. his III —THE HEBOID-PARANOID AFFECTIONS 163 he may change. a persecutory early. expansive ideas manifest themselves. the conspiracy embraced her mother. riches of which he has been unjustly deprived.

the presi- dent of the United States. psychosomatic sense.164 MENTAL DISEASES papers. it seems to me. or. to poison her. better of the general e. how little semblance of actual fact illustrates. the governor. in some unknown part of the world. The "feeling" of greatness hallucination. and the tradition survived him that he had a letter." and does no violence to suppose that the pleasurable noia are similarly hallucinatory. the Pope. similarly of may . of the actual existence of this estate existed. alcohol. induce We know that certain poisons. written or oral. not not a single writing. and yet upon a mythical tradition the patient built her vast superstructure of illimitable power. it states of parabe. The object huge plot was to secure possession of a vast fortune She believed herself to which she possessed. such hallucinations of "feeling. the king and queen of England. or even in large part.. To show how of this kind slender is is the basis of fact on which a paranoia based it should be stated that a distant relative had died about fifty years before. wealth. too. be a person of great consequence and influence. the president of France. Not a scrap of paper. some other origin. a halstill. we cannot altogether. they must have had some other basis. Ordinarily this form of paranoia is defined as one in which the patient evolves his delusions from actual experiences. mainspring of This. to do her to death. the mayor. she possessed greater power than the Pope. left an estate. can only be found in the "feeling" of the patient. actual observations and perceptions. to the tradition of a wealthy relative. not a vestige of any evidence. and. All of these persons were united in one vast conspiracy to injure and destroy of this her. the emperor of Germany. and world-wide conspiracy. and power must be looked upon as a lucination of [the cenesthesis. may suffice the case just cited fully ascribe the delusions Evidently. national senators. it g.

bearing the stripe of the Not infrequently disease. and physicians. having been committed. and. as has been pointed out. auditory. is may thus give relatives. with ordinary visceral and special sense hallucinations. in the form under discussion. mately associated with hallucinations — visceral. the patient. with hallucinatory states of the general body sense. inti- In the latter the delusions are. employs attorneys to secure his release. This is true also of hal- The difference between is this form of paranoia and ordinary it hallucinatory paranoia not quite as great as would seem. who stoutly resist commit- ment. Chapter IV). often extremely difficult and even hazardous to bring about the commitment of the patient to an asylum. the relatively high degree of lucidity in paranoia simplex. though in a much final less marked degree.GROUP toxic origin. or same who have more or less adopted the patient's delusions by con- tagion (see Part II. but they also are lucinations of sight. namely. he regards his com- mitment as merely an evidence of the conspiracy against him . and friends endless trouble. III —THE HEBOID-PARANOID AFFECTIONS 165 That hallucinations of taste occur in this form of paranoia can be inferred from the frequent presence of the delusion of poisoning. This lucidity is so great that persons coming into casual contact with is the patient may not suspect that he is insane. there are relatives. Hallucinations of hearing are infre- quent. met with. A point remains to be again emphasized. It is only when the well-spring of delusions tapped that the condition of the patient becomes evident. again. it is when some overt or unusual act Because of this relatively high lucidity. The patient himself so clear that he fully recognizes the nature of the legal pro- ceedings instituted to regain his liberty. and at times visual. the persecutory and expansive ideas are likewise associated with hallucinations. or attracts attention.

The patient.166 MENTAL DISEASES In other words. will reveal the truth. she claimed to have knowledge of a of which the sexual act could be prolonged in other method by means and repeated in- . if a woman. Every now and then sexual ideas dominate was the case in a patient the entire picture. who made the discovery that the sexual organs in both of man and and woman consisted two entirely separate parts. of paranoia presents itself with special Thus. sometimes." a limit of course to this suppression of delusions." She further declared that she had discovered a method by means of which the love organs alone could exercise their function without the reproductive organs taking any part. I at one time. or she is the victim of indecent profilthy. an un- expected thrust. asylums and physicians to get rid of litigation extremely. but I know now that that is There is not so. dislike and jury. accusa- tions against others. there is none. does not believe that he popes. "Yes. he suppresses his delusions. frequently claims to have received offers of marriage from distinguished personages. is the peer of emperors. the number of cases of paranoia simplex found in any one institution is extremely small. at other times she posals." certain structures which she termed the "reproductive organs. and yet the patient may to simulate the absence of the delusions so successfully as court. indeed. kings. Occasionally this form clinical features. and When confronted with letters and other evidences of his delusions in his did think like that own handwriting he may answer. words. declares that he has no enemies. certain structures which she termed the "love organs. erotic symp- toms are very common. as in ordinary paranoia. This. Sooner or later they come to the surface again. and decides to oppose cunning with cunning. for instance. namely. I don't think so now. deceive physicians. and are anxious these very troublesome cases. As a result. vile may give herself up to obscene. Finally. sooner or later a skilful question.

a glance in the patient's direction. had herself never it had carnal knowledge. fixed fee. exposure of the person. her other delusions. Sometimes the no doubt as an outgrowth of her sexual is hallucinations. one patient believed that a President. first. a chance meeting. when she was transferred to another institution. for This she advertised to do by private instruction. as far as could be ascertained. and upon one such occasion she was. after medical examination. and. at others she makes accusa- of indecent all proposals. again violated the law relating to the sending of indecent matter through the mails. to another city. Again. rape. and led in due course to the delusion that she had a "spirit husband. which she proposed to charge a and she also wrote and had printed pamphlets which Later. when she release finally secured her by disavowing. tions seem to have become very vivid. More frequently the eroticism manifests patient. finally." At various times the sending of her pamphlets through the mails brought her into conflict with the postal authorities. again announced her views. she conceived instruct to be her mission to mankind in her discoveries. was arrested. assaults of kinds. Thus. and . believes that there a conspiracy to defame her character. her belief in her spirit husband. sexual hallucina- she disseminated in various ways. Although she was unmar- and. 167 this definitely without She called state the perpetual ried. itself in other ways.GROUP ni —THE any HEBOID-PARANOID AFFECTIONS risk of impregnation. a phrase upon the stage. After her release she removed and. to tions impugn her virtue. convince the patient that this or that prominent person is in love with her. the She presented such a high degree authorities of lucidity that hospital contemplated her discharge. killed herself by the inhalation of illuminating gas. committed to an asylum. with whom she had never exchanged a word. a few lines in a newspaper. finally. honeymoon. Here she remained a number of months.

and even murder circumstances.) At times. Again the heir deprived of his heritage. . the victim of political conspirators. cruelty. the patient writes times again— usually many —and. are not wanting. may occur under these the delusions As we shall see a little later. and abuse. Chapter Sometimes the delusions assume a poHtical character. that rightly elected to this or that office. of which he is the machinations of his enemies. Not infrequently. the rightful ruler. into every act. he has been deprived by ment persecuting him. or loved one. forties. Accusations. is that he an important political personality. If answers are not received. husband. may assume the character fidelity. spied upon. ing That much suffer- may thus ensue to the unfortunate object goes without saying. especially in of clearly-marked belief of marital in- the so-called alcoholic form of paranoia. again. The latter is is watched. that information being lodged against him. that spies are upon is his track. every innocent word woven is the delusions. of reprisals. the patient is an old maid and near or at the menopause. The husband com- believes that everybody trying to seduce his wife. who Occa- sionally such patients write amorous letters and in other ways subject the object of their delusions to annoyance and even persecution. was anxious to marry her. persecution. she cannot move pany about. still receiving no response. patient believes that he is The being watched. sooner or later enters upon a campaign of threats. perhaps.) (See Part II. and that they may assume most he is varied forms goes without saying. Chapter I. she is in the early (See Part III. that he is in danger of arrest is and imprisonment. sometimes assaults. paranoia assumes the form of an insane jealousy of the wife. vilification. I.168 MENTAL DISEASES already had a wife. speak to. or permit herself to be in the of the opposite sex. that the governOf course the expansive delusions.

full but. it may be. and just he seeks satisfaction through the law. an estate has actually been divided. assumes the form of a The patient believes that he can only obtain redress for his wrongs in the courts. the hopelessly illogic contentions of the patient. One of these patients brought action against it her relatives because of fraud in the division of an estate. as he believes. but that he has suffered wrong. this or His counsel has played him that witness has betrayed him. mistaken. that he is so and the presentation little may have difficulty in securing the services of an attorney.. he has been vilified. and even the judge has been in collusion with his enemies. However. perhaps the case In- evitably the absurdity of the situation. e. a systematized delusion false. because he beheves himself to have been unjustly of treated by the executors an estate. On the contrary. become apparent. lucid.GROUP III —THE HEBOID-PARANOID AFFECTIONS affection 169 Every now and then the paranoia of Htigation. attorney. the witnesses. but he fails utterly to comprehend that he has been in the wrong. or even that he has used bad judgment. the members of his family or his business associates. libeled. i. the patient did live in a certain neighborhood. certain business transactions have really taken place. be. Sometimes there sufficient basis in fact to give coloring to the patient's conten- tion. had subsequently been a charge upon the other members of her family. perhaps did not have friendly relations with those about him. To show . the patient frequently of his case so plausible. the jury has purposely made common cause against him. defrauded of his inheritslandered. he now weaves the lawyers. the untenable character of the claim. does not of course follow. He brings suit. is or. was quickly proved that she had not only been paid her share. Usually the facts developed subsequently reveal that the patient has no case. the judges into of conspiracy. it may ance. the jury. He may then take the matter to another eventually reaches trial. because of her improvidence.

as a from hallu- cinations." have a "mission" to perform. the offending relatives lived next door. hereditary factors are is very pronounced. Frequently. who become his partisans and champions. the woman had impressed one of her friends. everybody shall have his share. vnth the justice of her claim. Often much suffering and unhappiness result. It which she declared they had attempted to poison was shown that she believed that her had wired her house. they aim to reform the world at a single blow. the period of depression sometimes difficult . the patient impresses his delusive ideas on others. and she had actually. nor are they the victims of mystic ideas. chopped off a large part of the plaster in her parlor in a search for the wires. too. suffer These persons do not. a rule. there shall be no more poverty. and he had actually gone so far as to join her in the plaster-chopping search for the wires in the parlor. Her case was is of course easy of solution. there shall be the advent of the rule.170 MENTAL DISEASES inimical her relatives were to her. however. Unfor- tunately the situation not always cleared up so readily. is finally Not infrequently. before the insanity of the plaintiff established. she how — unexpectedly to relatives her counsel —produced also a bottle containing some decomposed cherries with her. Sometimes the facts are quite involved and complicated. with a hatchet. clearly lawyer after lawyer is consulted and suit after suit instituted. everybody millenium. as in religious paranoia. In the case just mentioned. a minister. As a rule. An interesting and often troublesome form exhibited of paranoia is that every now and then by persons who conceive As it to be their mission to accomplish the social or poHtical regen- eration of the world. to make humanity good and happy. ills they advocate some utterly impracticable panacea for the from which the world suffers. be happy. no more shall suffering. they also are "called. no more injustice.

Throughout he reveals a personality expanded beyond all bounds. The individual writes literary or scientific articles and l^ooks. Occasionally the expansion expends literature. person becomes evident after a while even to the He At may. others fail where to see it. a self-confidence so extreme that he does not hesitate to jeopardize the means and savings of relatives. friends. sees evil Quite frequently he speaks. we find traces the long periods of trial and discouragement before the patient believes that he has really attained his object. lectures. for a long time obtain a deluded following. the depressive period of it in is usually not marked. however. writes. He has an overwhehning confidence assertive and aggressive to a degree. in is is The expansion obvious. (See also Part n. such as perpetual motion. As a rule. the gross char- acters of the delusive beliefs sooner or later lead to the recognition of the truth. of the patient in himself.GROUP to trace. art. happily at times very early. and others. all times his ideas are frankly out of keeping with his sur- roundings. he beUeves himself to be royalty or destined to become king or emperor. Weakness and absurdity. itself in the direction of or invention. HI. As in the other ambitious forms of paranoia. sometimes the degeneration progresses and he believes himself hearing are to be the Deity. undertakes art some great work time . difficulties is He speaks terms of exaggeration alike of the with which he contends and of the great things he going to accomplish. of upon which his fame is to endure for all or he devotes himself to some invention. at times. the mental state of such a laity. however. Hallucinations of met with in a small number of cases. quite frequently something chimerical and impossible of achievement. Not infrequently he wastes his substance in the attempt to further his projects. III —THE HEBOID-PARANOID AFFECTIONS is 171 though not infrequently there an antecedent history of a long-continued period of general ill-health.) . Chap.

may terminate in recovery. remission. has. especially a first attack. —That paranoia presents itself under exceedingly- varied forms the above descriptions clearly show. more apt to be the case when the symptoms is. cases beginning as acute paranoia may. and that years afterward such an attack may be followed by a second or even a third. or cases eventuating in chronicity may begin with is rather an active onset of symptoms. In para- noia hallucinatoria. the outcome attack. by the existence of transitional forms. while. e. that when they Again. and even at times. the paranoia acuta of the Germans. General Considerations and Conclusions. The whole process extends over indeed. fifteen. though to the asylum. every alienist will recall cases in which the patient. are relatively rapid in onset and course. to transformation of the personality. it is many years —ten. in the non-hallucinatory forms of para- The between paranoid dementia and paranoia hallucinatoria as has already been shown.— 172 MENTAL DISEASES Prognosis of Paranoia. the state. though rarely. under greatly disturbed upon admission the quiet and simple regime of the institution. an individual on the whole. in paranoia hallucinatoria However. pass into the chronic form. and the expansive a final period of deterioration or dementia.. the average course consists in the passage of the patient through the period of persecution. approximate the acute form of dementia paranoides. shadow what we are These facts in a measure fore- to expect in the chronic form. The picture presented by delusional lunacy ranges from the paranoid de- mentia of dementia prsecox (i. rapidly and . to begin with. twenty-five practically a life-long disease. mental deterioration becoming finally more and more pronounced. We have seen that in paranoia acuta unfavorable. the lucid states noia. though This is rarely. one of degree. delires systematises aigus of the French) to the met with relation is. we note now and then of a distinct abatement a clearly marked symptoms.

especially in the mystic form. the progress of paranoia steadily toward mental deterioration. evolution. It its full especially in the non-hallucinatory form that fixation and elaboration find their fullest expression. it is may be said that the progress of a hallucinatory paranoia not subject to marked interruptions. and a marked terminal as we have seen. is however. during the early period. As a rule. remains to emphasize the fixation of the delusions. and. the patient's mental state sooner or later reasserts itself. In the hallucinatory form. a hallucinatory form. in ordinary hallucinatory paranoia the deterioration becomes more and more evident as the years pass by. unalterable. exceedingly slow. sometimes so much so that well-meaning. On the whole. and more especially the paranoia which as- sumes the form of social. this the case In non-hallucinatory paranoia the change.GROUP III —THE HEBOID-PARANOID AFFECTIONS 173 greatly improved. be preserved a long time. such variations as are noted are rather in the nature of accentuation of symptoms than in their abatement or remission. the degree of change and the rate at which it is established vary greatly in different cases. Relative lucidity may. stage of terminal dementia is until finally a reached. as a rule. at least not as long as the under observation. Finally. As has been pointed out. friends or relatives have insisted upon the patient's discharge. of course. though mistaken. Such improvement is. political regeneration. the paranoia which assumes the artistic. save for some elaboration. tem- porary only. itself bears close resemblances to mystic paranoia. is Again. though preserving their general character. the literary form. is not as great as would at first Thus. the delusions. but not after the affection has reached is may vary somewhat. is dementia patient is may it never be reached. the difference between ordinary hallucinatory paranoia and the non-hallucinatory form sight seem. . Once they have become established and systematized they remain unchanged.

because. on the other. evil cults. especially is this the case with scientific. Many of the non-hallucinatory paranoiacs are dangerous. it may present itself with such a high degree in the of lucidity. the writer. the patient still As already pointed by out. on the one hand. with arguments so plausible and specious. the asylum authorities are often anxious to get rid of them because of the very troublesome litigation sooner or later instituted by the patient or misguided friends. the inventor. but really quite without danger. some are and their views so plausible. presents itself with features so striking and unmistakable that even lay persons recognize the patient at once as insane. They are often committed with considerable risk to the examining physicians. every community. that not only may lay persons fail to recognize the insanity. Paranoia it is a remarkable affection. Others again are quite harmless. on the whole. as in mystic paranoia. as paranoia of the reformer. . sometimes amusing. even the opinion of physicians delusional lunacy. those whose delusions are concerned with literary. but may even adopt the delusive ideas of the patient.174 MENTAL DISEASES is This also true. though less markedly. because of the high degree of their lucidity. while. Concerning some of them as to the fact of a real may differ Comparatively few of the non-hallucinatory paranoiacs are. that they are often merely regarded as "cranks. artistic projects or and with inventions. the agitator. and pernicious doctrines. of the paranoia of in- vention and discovery. as already stated. found in the asylums. they are less so as regards assaults upon the person and attempts to kill than are ordinary paranoiacs. further increases the difl5culty suppressing his delusions. Many of these are among so the harmless lunatics found in lucid. Many of them are harmful in the way of dissemi- nating dangerous theories. though. Indeed." sometimes annoying. are often retained in the asylums with difficulty. and.

with this fact. e. some factor other than simple nervous exhaustion plays here a role. In the demands that modern civilization makes upon the individual. the "fatigue neurosis." which the writer has on various occasions applied to it. It is the symptoms of this fatigue 175 . and concerning which there has been much The close relation which some of these affections. a feeble resistance to fatigue. however. is of frequent More especially the individual has inherited a tendency i. Its among physicians as neu- symptomatology is essentially the it tology of chronic fatigue. a brief consideration will. more espe- cially the phobias. and for this reason well merits the term. bear to neurasthenia was early recognized by Beard and subsequently confirmed by others. with a definite symptomatology. results in is undue expenditure over-fatigue. Gradually a well-defined neurosis. is Under such circumstances a condition neither the normal estabhshed in which amount of rest nor food suffice any longer to restore the organism to the equilibrium observed in health. convince us. an expenditure that occurrence. I believe. That. this true if of energy.CHAPTER VI GROUP IV— THE NEURASTHENIC-NEUROPATHIC DISORDERS (PSYCHASTHENIA) The group of affections which forms the subject of the presis ent chapter one concerning which much has been written. and this is widely known among symptoma- the laity as nervous prostration and rasthenia. becomes established. chfference of opinion. to nervous exhaustion.. In keeping the French writers applied the term "neuras- thenic insanities" to this group.

and. sensory. we find that it rapidly grows The various statements which the patient makes are in keeping with this finding. in addition. When we turn our attention to the motor symptoms. quite commonly the knee-jerks are exaggerated. a brief consideration of the others serves to complete the picture. we find a diminished inhibition of the tendon re- flexes. be tested by the dynamometer a number of times weaker. for instance.176 MENTAL DISEASES symptoms have on the mental us. that slight muscular exertion of any kind rapidly exhausts him. in succession. The phenomena presented by neurasthenia symptoms. In keeping with this fact also that of irritability. from without. however. and of other structures such as the sexual organs. expenditure is is physical or mental. Some- times also tremor. but. besides they are not infrequently pres- sent in a degree in the mental affections we are about to study. He will state. of deficient inner- There are present. the symptoms vation of the digestive tract. that he cannot walk even for short distances without inducing fatigue. general somatic. of the circulatory apparatus. of exaggerated response to stimuli is. neurosis and the bearing these affections under consideration which particularly concern fact that impresses us in neurasthenia is The first that the patient becomes readily exhausted. while naturally resolve themselves into motor. if it seems to be normal. In keeping with this ready muscular exhaustion. that along with the lessened power of susis tained expenditure of energy. grip of the patient it is Thus the found to be weak. He This is is incapable of the true whether the sustained expenditure of energy. irregularly recurring contractions of small bundles of muscle fibers. occasionally. more especially in the face and ex- . there also a lessened inhibition. and. we find that the muscles rapidly reveal the signs of fatigue. indeed. and psychic it is the psychic phenomena which chiefly concern us.

. sensations of weight. are never present. NEURASTHENIC-NEUROPATHIC DISORDERS 177 tremities (myokymia). Thus the digestive disturb- ances are primarily those of weakness. and which he refers to the trunk. we learn. constipated. but are doubtless to be interpreted as due to defective and irregular innervation. is also In other words. the symptoms are those of an atonic indigestion. but. The sensory phenomena jective. We note coldness. The patient. in the calves —may be present. Quite fre- quently the patient complains merely of a general feeling of fatigue or exhaustion. GROUP IV —THE g. or pressure about the head. in marked cases. hj^esthesia. as already indicated. At the same 12 time.. or a sufficient movement in the walls of the stom- ach and intestines. the limbs. aches. at other times of lightness. The patient complains pains. the same fact of deficient innervation becomes evident. of neurasthenia are altogether subof various fatigue sensations. such as anesthesia or The somatic disturbances are. depend- ent upon a deficient innervation. or dizziness. These sensations are always brought on or made worse by exertion and disappear or grow less upon rest. the head. constriction. we find modifications in the force and rhythm . oppression. Uvidity of the extremities. These symp- toms may be regarded as adventitious. There is not a sufficient flow of nervous energy to the glands and muscular coats of the stomach and intestines to allow either a sufficient secretion of gastric or intestinal juice. and of general discomfort in the epigastrium make their appearance perhaps there are eructations. of and even occasional cramps or spasms muscles—e. should be emphasized that objective sensory disturbances. The patient having taken food may feel at first no distress. and. When we turn our attention to the circulatory apparatus. after the lapse of a longer or shorter interval. it may be of uncertainty and It Insomnia is very frequent.

or at least in so close a relation to spontaneous attacks of fear in neuras- thenia that they cannot be dissociated is exceedingly probable. evoke the associated emotion of is That this actually occurs in neurasthenic patients a clinical fact. in neuras- However. brought on in a normal is by a sudden physical danger. and other vascular phenomena. Everywhere we note the for in- fact of deficient innervation and deficient inhibition. Not rarely the of a man and unmarried. fear is normally and intimately associated with quickening of the pulse-rate. in the character and more or less marked alterations in the vaso-ihotor tonus. Thus. fear. These are main those Occasionally they are so marked as to clinical picture. That these stand in a causal. a brief summary of the symptoms is necessary in order that the importance and even magnitude of the role which they sometimes play patient. of the heart's action. form a prominent part of the Although the objects of the present chapter forbid an extended consideration. at times there less persistent is present a more or tachycardia. sudden pallor. coming on suddenly in its turn and spontaneously. Among the more important somatic phenomena in the are to be included the sexual disturbances. of irritable weakness. so may this very pal- pitation of the heart. just as an attack of individual tation fear. presents the symptom .178 MENTAL DISEASES and frequency of the pulse. often with a frank and outspoken palpitation of the heart. The circulatory phenomena of neurasthenia are of great importance in relation to the mental affections of the present group. the presence of pulsation of the aorta or great vessels generally or of local pallor or flushing of various portions of the surface or extremities. if may be understood. In other words. attended by palpi- and other vascular disturbances. stance. the most striking circulatory disturbance thenia is palpitation of the heart. relation.

may In symptom of premature ejaculation or of the sexual act being incomplete and unsatisfactory in other ways. and may state that these are If accompanied by oppressive and voluptuous dreams. The psychic disturbances ready mental exhaustion. mind and their signifi- To this subject we will return later. such symp- be present. present the married. the act may be incomplete and unsatisfactory. and will-power. loses personal force. in the spontaneity of thought. as already indicated. Finally. women symptoms occur. after all. At the same some of his who is chronically tired. proper response. Without pausing to consider other somatic phenomena of neurasthenia. the patient. their importance in the patient's becomes exaggerated cance misinterpreted. just as it. He becomes unable to decide. difficulty in is sustaining and concentrating the attention and there also a marked diminution time. aggressiveness. They are due to the ex- much as are the digestive or the circulatory phenomena. as in the male. even ordinary or trivial matters. with his usual readiness. may complain There may be failure of These symptoms. lack of spontaneity and lack of . are usually but a part and parcel of the symptom group of the general neurasthenia and are directly dependent upon haustion. everything that requires any effort remains undecided. present. or. because they are sexual. first. whether occurring in men or women. toms are of less likely to married. the most important. frigidity. but. a patient complains of orgasms oc- curring during sleep. if 179 unusual frequency of seminal emissions. delay. There is marked diminution There is in the capacity for sustained mental effort. but the patient some abnormality of the sexual act.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS or. matters of business. Unpleasant and pleasant matters alike are deferred. corresponding to those in the male may Not infrequently. which are. let us turn our attention to the psychic symp- toms.

attacks which are generalized in character. ill-defined. and the natural may be looked upon as concomitant of the other mental symptoms. the patient frequently presents the symptoms of fear.. That a person whose nervous system is is exhausted should also be morbidly afraid perhaps not surprising.. the uncertainty. a play at the theater or a newspaper account of a tragedy may In addition. easily. and which may be properly spoken Typical of such of as attacks of spontaneous generalized fear. He not only becomes move him to tears. of inhibition. At times the other times fear amounts to a general feeling of anxiety. e. and at times very much frightened. His emotions generally are aroused more easily than normally. accompany Under these circumstances the patient becomes anxious and distressed. but. attacks are those which in some neurasthenics attacks of palpitation of the heart. At it comes on in sudden attacks. well That the tired man is cross is known to the laity as to ourselves. hesitaindecision. when not angry more tired. i. and habitual is Again. for weakness and fear seem naturally to be associated.— 180 will-power tion. the pulse becomes small and . e. cardia. readily. the indecision. may be vague. namely. the face pale. There is a sense of distress in the precordia feel as a "pain about the heart" —and the patient may There is though something itself terrible were about to happen. the were impending. uses expletives and expressions. subconscious. He becomes excited more says things to which. of the The degree It emotion varies greatly in different patients. a as diminution of inhibition. there a markedly increased irritability. on the other hand. he would not give vent. MENTAL DISEASES may be frankly accompanied by uncertainty. his irritability is i. as though death a sudden onset of tachyrapid. only a more or less marked loss of self-control. the lack of will-power.

the patient simply becoming Such tensely nervous. and indeed commonly. states are quite frequently misunderstood by the practitioner and in- correctly characterized as hysterical. but the the limbs may break out into a cold sweat. the attack be severe the patient symptoms may not stop here. sometimes the the purely nervous visceral phenomena precede. anxious. but. that to such changes in the as to constitute "manner insanity. thinking. The bowels may in be suddenly evacuated. of acting. special visceral frequently in other Sometimes the fear comes on without in- symptoms. he may become faint. Finally. may become relaxed. Neurasthenia may present itself. Usually evidences of such a neurop- . Severe attacks occur. come on more pronounced and it is a common less experience for these feelings to be accompanied by distress in the region of the heart. and feeling" In order that this should result another factor must less be introduced. the sphincters from other causes. or the bladder may become relaxed. a more or ropathy. Such a neurosis does not is. restless. namely. and afraid. as a simof itself lead to ple fatigue neurosis. marked degree of neu- A non-neuropathic individual may from overwork must previously or other nervous over-strain develop nervous exhaustion. perhaps in the abdomen. especially women. from a mere "fluttering" of the heart to a very grave seizure. or portions of the body. the respiration hurried and irregular. and they vary of course greatly in degree. changes in the quality of mind. he may sink into a chair or As in intense fright even to the ground. free There are few neurasthenics who are altogether fear. he have been neuropathic. in order that he should develop a psychosis. from or are there are at least anxious feelings which at times. as above outlined. sometimes.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 181 If expression anxious. both groups of symptoms seem to come on simultaneously. sometimes follow phenomena.

Thus. of changeable temperament. the history of a child fussy or fastidious in the extreme clothing or belongings. It is make-up and fatigue in the heredity of in only when symptoms appear This truth such a subject that mental disease results. little tricks awkward and even clumsy and often betraying peculiarities of gesture. child easily their play. is and gravity sometimes it the history of a child given unduly to reflection. or peccadillos. the morbid conscien- tiousness previously noted becomes accentuated and the pathis may become scrupulous to a degree. or. ment. lack —may also become emphasized. ties with duties at school or other sometimes with religious matters. of person these affections make We soon time learn that they come on in individuals who for a long previous to the establishment of the symptoms have not been normal. or limbs. undecided. necessary to learn in what manner their appearance. and. timid. tricks of the fertile soil upon which the neurasthenic-neuro- . itself Sometimes scrupulousness concerns tasks. twitchings of the too.182 MENTAL DISEASES in the athy are revealed both the individual. In order that we should have adequate it is conceptions of this underlying neuropathy. day-dreaming. is of action. irritable. its fellows. unstable. patient Often we receive a history that in childhood the was unduly impressionable. faults. at the same time. Quite commonly. head. on the other hand. excess- about its ively conscientious. rumination. it is facial muscles. the history of a dominated by not joining the latter in in physical exercise. it is and lacking in initiative. shy. the indecision. The other peculiari- manner This —the hesitation. of moveoften. exaggerating the importance of its Uttle misdemeanors. will become more evident as we proceed. About the time of puberty. the peculiarities of the patient may become more tient pronounced.

signs of gastro-intestinal atony. and extremities. sometimes a bulimia is present. distension. The headaches not infrequently pronounced and tenacious and are often described as neuralgias. as in neurasthenia. they are characterized by delayed and enfeebled digestion. as does also the ordinary neurasthenic. Sometimes. Quite frequently he complains of insomnia. The sensory phenomena are revealed by are pains in the head. too. turn our attention to the physical symptoms. Sometimes. the appetite is well preserved or even exaggerated. also. much .GROUP IV —THE NEURASTHENIC NEUROPATHIC-DISORDERS but. or of pressure in the temples and back of the neck. or a feeling as though the head were empty or caving in. we find that the latter in neurasthenia. are the In a general way. in short. The motor phenomena are evidenced by readiness of fatigue. 183 pathic mental disorder develops. On the part of the circulatory apparatus is we note that palpi- tation of the heart very frequent. a want of energy. constipation. are constantly present. as in the con- sideration of neurasthenia. he speaks of dizziness. the circulatory phenomena are identical with those of ordinary neurasthenia. eructations. trunk. offensive breath. flushes of the face or other portions of the body. detail the before taking up in mental symptoms of the first latter. In other words. same as those present and they vary in degree from those of simple nervous fatigue to those of pro- nounced nervous exhaustion. coldness of extremities. The skin is sometimes dry. such as shaking or creaking in the head. that the cardiac rhythm is very variable. there are also the general signs of loss of vascular tone. Digestive disturbances. let us. an absence of resistance to tire. sensation of weight and fulness. Now and then he describes bizarre sensations. the patient complains of fulness and tension in the head. As before. indeed. pallor. As before. by the As in neurasthenia.

Similar conditions to those already outlined as occurring in the female in neuras- thenia also obtain here. there is a history of excessive is nocturnal emissions. (See An important point also to be borne in mind of the patients is that a certain number —a small number—present the signs of This is deficient thyroid activity. and by a significant.) may even be more pronounced. irresolute. in The first resemble the general features met with effort neurasthenia. The latter has a sense of The patient "inadequacy. These are first The are all part and parcel of the state as a whole. the sexual functions present the phenomena of irritable weakness. though perhaps skin. or in coition the erection apt to be in- complete and the ejaculation premature. is For instance. 179. There are not present the clearly marked symptoms signs of a of a myxedema. Let us now turn our attention to the psychic symptoms met with in neurasthenic-neuropathic mental disease. hesitating. infiltration is and dryness by a pulse rate which rather slow. more frequently the patient quite com- monly the hands are not only cold but moist. retardation or slowing in the mental processes.184 MENTAL DISEASES perspires rery easily. save that they p. fearful. in both male and female the symptoms are identical with those already outlined for neu- rasthenia. merely the moderate degree of thy- roid inadequacy. separable into general and special symptoms. Indeed. seen in some by an unof the doubted. Sometimes the patient sweats very readily about the head and neck. timid. slight. the lack of sustained here also present and is and spontaneity clearly recognized by the patient. and are found in cases." is of powerlessness. As in neurasthenia proper. The feeling of inadequacy reveals . of insufficiency. though not marked. the second give to individual cases their special clinical characters.

that the patient easily upset. impossible. sometimes he feels that he cannot freely make a new single gesture is and with if ease. the anxiety psychoses). need hardly be pointed out. the Insanity of the Special Fears (the phobias and obsessions. the patient incapable of persistis. seems to be natural and to represent the actual clinical findings: First. ence and concentration. The special fears differ from the general fears. are added special To these and thus general symptoms there by symptoms arise the various clinical forms. different writers. the Insanity of Deficient Inhibition. Third. and disturbed. excited. Merely the idea of having something to accomplish is may frighten the patient. This feeling of inadequacy usually exaggerated the task or movement is or if the patient happens to be in the presence of strangers or in public. is That there is also a diminished inhibition.GROUP itself IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 185 both in the actions and in the mental operations of the patient. Fourth. so convinced he of his powerlessness to achieve a result. in that . is Some- times the feeling so pronounced as to lead to discouragement of the patient and hopelessness on the part found wise inertia. This condition of course. for but the following which I have employed many years. These have been classi- variously grouped fication. If and even to a pro- the patient attempts mental work. this likeis is difficult. the Insanity of Deficient Will. It is at once seen that each of these forms or symptom-groups has its prototype in the psychic phenomena present in ordinary neurasthenia. continuous coming on in attacks. and that he or is also the victim of fear. insepit arable from an impairment of the will. the Insanity of Indecision. He can do nothing hke the rest of the world. and coupled with is there a feeling of uncertainty and doubt. Second.

may but pass if. a closed space. e. glass may give less. so that afterward every attempt to cross brings on an attack of fear. or occurrences. anthropophobia at others of being alone. special objects. The tendency to multiply names characterize these conditions has happily grown Some . have a nervous ex- haustion merely expressive of chronic over-fatigue and occurring in an individual off not especially neuropathic —the be attack effects. the patient be morbidly afraid of the dark. readily understood. comes linked to certain a Thus. fear. g. a patient has a spontaneous If attack of generalized fear. without leaving any persistent after- in addition to being neurasthenic the patient i.— 186 MENTAL DISEASES they are related to special places. it may still be the fear of being in crowds. relate to special conditions of the environment.. special events. The fear of open spaces is known technically as agoraphobia. such as has been described. is The number very large. man has an attack of spontaneous generalized fear while crossing an open space. a claustrophobia. nyctophobia. How some of them may arise can be For instance. immediately there is formed in his mind an association between the attack of fear and the open an open space space. At another time . a large extremely probable that number of the various special fears arise in some such manner. The association between the open space and the fear is of course pathologic It is and would not be formed in a normal individual. patient be merely neurasthenic the —that is. monophobia. or e. so that the emotion of fear berelations of the environment. Similarly.. for in- stance. also neuropathic if he have the psychic and physical features already outlined —a pathologic association may be formed in the patient's mind. the fear may arise of being in a small room. rise to the to of crystallophobia. of It forms which the fear may assume may of course may. contact with certain substances.

A repri- mand at school be followed by a phobia with regard to a certain class-room. unnecessary to describe and which are. Unpleasant experiences at home. emotional state —dread. but the obsession. persists. or in the adult of his career. his head.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 187 them are. may dislike. ness. as they serve to at once convey the idea of the character of the present. worthy of being retained. or perhaps of repeated prolonged and unsatisfied sexual excitement. in busi- may is be followed by obsessions. his face. physical or mental. is the term mysophobia. may occur in engaged persons in detail. however. a certain teacher. Sometimes the original cause forgotten. in a vain filth endeavor to remove or to rid himself of germs. Because of the peculiar relation which life the sexual functions bear to the moral and social of the in- . in older patients. such as . The phobias and special fear is obsessions may have an origin in which the not based upon a spontaneous attack. breaches of conduct. embraced by the expression "sexual traumata. by the wholesome and often trying experiences Among the causes of the special fears are at times various acts of the patient. symptoms Among them filth. of which he is subsequently ashamed and which he willingly tries to forget." in class of common use among a certain medical writers. his person. or the patient may have had other sexual experiences. disgust. are frequently acts relating to his sexual Among these It may happen that the patient presents a history of masturbation. of the proprieties. but upon some special occurrence or produced by some kindred painful abhorrence. or. and are not to be confoimded with the corrective memories produced in the child by punishments. peccadillos of various kinds. used to desigis nate the fear of In this condition the patient constantly washing his hands. Of course such symptoms can arise only in neuropathic subjects. the phobia. a certain school book. fife. at the present time.

Persons of ordinary healthy make-up often show surprisingly few symptoms as a result both of unphysiologic as well as of excessive sexual living. excluded from the field of conscious- The second truth. the greater the effect on the mind both of the sexual symptoms present must be in a given case and of past sexual traumata. withdrawal or reservation of emission —are not as grave or as baneful as they are fact. the experience of physicians has As a matter increasingly shown that the physical consequences e. In other words.— 188 dividual. but if he have the neuropathic make-up here described. to the masturbation. not so first. (See Part III. tient ideas. with its train of distressing symptoms. their influence sistent. coitus interruptus. commonly supposed to be. by an unpleasant revulsion of feeling. In an individual otherwise normal. The individual usually tries to forget or repress the recollection of an incident which is quite usually followed is. sexual traumata. which will become more apparent a little later. and ness. In their evil consequences have been much exaggerated. the use of the cover. is. have but little effect.. Gruebelsucht) . Two truths is become apparent. Chapter The insanity of indecision (the fohe du doute." associated unpleasantly in the patient's mind.) sessions. as far as possible. Again stress laid upon the factor of neuropathy. the effect of a sexual transgression much physical as mental. so-called. the patient MENTAL DISEASES is apt to ascribe his nervous exhaustion. reservatus. may be far-reaching and per- and thus may prove a manifold cause of fears and obI. or other sexual misconduct that he or she has practised or permitted. is that the greater the tendency to nosophobia and introspection. of mastur- bation or of modifications of the sexual act g. the pa- may develop a nosophobia which centers about sexual of fact. that the incident is after a "sexual trauma.

putting acts. would take minably. but he could rarely get out of his article of clothing. arranging his clothletter. The patient never quite sure that that which he has done has been done correctly. and began to be uncertain about his He was compelled to re-add the same columns time after time. Again. feels not certain. he may spend a large part of the night Similarly he in this hopeless effort to be certain. agony of doubt. in a perfect and had often to abandon the task utterly exhausted. The symptom of indecision is. The patient may betray his indecision about the simplest ing. as we have seen. is really turned off the gas. on again.GROUP is IV THE NEURASTHENIC-NEUROPATHIC DISORDERS 189 merely an exaggeration of the mental state so often observed in the ordinary neurasthenic. a bookkeeper who had been very finally expert in adding long columns of figures totals. it off. broke down. already part . room before twelve. goes to bed. however. but only to leave he bed to see whether he has the key. upon the and may finally turn out the gas and go his to bed. but only to rise again and to repeat the per- formance. such as dressing. and then suffered in- was uncertain as is to what the number really was. He would put on an it would doubt whether he had put put it on right. and repeat difficulty at its this act inter- Especially was the maximum when it he attempted to put on his neck-tie. to sleep. It is not. indeed. adjusted properly. in arranging his clothing chairs or other furniture. One of my patients would begin to dress at about half past seven in the morning. On going to bed he may spend endless time in undressing. may spend half the night locking and unlocking doors. jet. an address on a Many minutes and hours may thus be consumed. he could never get Another of my patients could never enter a room without counting her tensely because she footsteps. save that it in now presents itself an extreme degree. relights the again turns the key.

the indecision. instead of expressing itself hesitation of action. is writer the insanity of among the most interesting that we have "tics." compulsion neurosis. These impulses are ." "impulsive movements. or of the number of burners on the chandelier." pulsions" generally." to study. doubts of the child concern themselves with school duties. Something that has read or heard in conversation on the subject of religion or morals may give rise to endless scruples and doubt regarding its own conduct. —with the environment. Some ing a patients spend their time in speculating still upon or doubting enterit the reality of things. while the Germans have largely employed the expression "Zwangsneurose. others are unhappy because on room they are not certain of the of books number of chairs con- tains. Sometimes a special character is given to the scruples by some other experience. of the number upon the table. such as the dis- covery of the facts of reproduction or of other sexual matters. It embraces the great mass of cases with "impulsive tendencies. an emotional shock. is constantly eliminating of the interaction impulses. The of the brain. The symptom group. associations. These impulses are the resultants its mind and activities — previously acquired memories. and are never quite certain. may expend it upon purely subjective matters. Consequently they count and count again. under normal conditions. the French speak of obsessions with irresistible tendencies. or must keep on counting to reassure themselves. termed by the deficient inhibition. itself in As it grows older. and "im- The English writers use the term in- sanity with irresistible impulse.190 MENTAL DISEASES of the impressionist and parcel background of neuropathy seen in the child and that it becomes more pronounced as puberty Quite commonly the worries and and adolescence are reached. as we have already pointed out.

Quite frequently a vulgar word. anxious to prevent is it. less phrase. The control and inhibition are alike potent —indeed. he but is powerless to do so. that jected into the patient's speech. indecision. a case whose principal symptom a failure of inhibiIt is tion may also present a phobia or obsession. a patient attempts to carry is on a conversation. very apparent. restrained. earlier We pointed out that in the underlying neuis ropathy of the neurasthenic-neuropathic patients there a in group of general symptoms. of the and that is the origin. are is more forcibly exercised —when the discharge of the impulse is attended by displeasure. therefore. and that each case is classified accordance with the predominance of this or that special symptom. in other words. which kno^vn as coprolalia. that a case presenting a presents though is less prominently. inhibited. and use- organism they may enable it to accomplish a definite object. thus inter- Less frequently is is it is a harm- The symptom. These movements ful to the or determinations are normally purposive . disgust. phobia also It follows. that there another factor to be considered. In the pathologic state we are studying there of such inhibition. such a phobia or obsession acquired in a manner already indicated which . is an oath.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 191 dif- normally controlled. they fused or they may be may be directed into special channels. word have or phrase which thus forces itself to the surface. or pain. however. an obscene or profane expression. an absence For instance. occurs in spite of the patient's will. the raison d'etre. similarly. every sentence that he utters iDy interlarded a recurring word or phrase that has no relation whatever to the content of the sentence and is entirely foreign to anyit is thing the patient intends. there It is a failure of is inhibition. and thus expend themselves in movements or determinations. or they permit of the harmless or pleasurable release of energy.

an is arm as raised. may be associated unpleasantty in the There is an unpleasant feeling which the patient . how- and now forms some new and entirely pathologic association with process. which give birth to the phobia patient's mind. but in the latter such associations are repressed and inhibited . that is. often vulgar. an attack of fear results. If the association is of a if given character. field of consciousness. movement known as a when widely diffused and severe." of These movements usually have the appearance voluntary or purposive movements. The head is is flexed upon the chest or turned to one side. save that they occur suddenly and spontaneously and usually without any relation to the environment. used here as an illustration. associ- ated with the coprolalia a disturbance of "tic. associations. of pathologic." or. it is would unhesitatingly answer the formation of abnormal. tries as far as possible to forget that is. or profane in the normal mind. some other mental is process. is quite commonly but a there is part of a larger psychomotor discharge. driven from the ever. as "tic convulsif. associated with coprolalia they are not necessarily If I were asked to name the one all symptom which that is more important than I the others in the neuropathy we are studying. or as though right. the events finds here its expression. The role which defective inhibition that the pathologic as are plays becomes evident when we reflect associations are formed in the same manner numerous others. Sometimes these gestures occur in group movements of great violence. a gesture off made though the patient were warding something. a tic results. Though frequently so. bj^ reason of its unpleasant association. indecent. usuallj^ an emissive In keeping with this the fact that the symptom of coprolalia. the memory is of the origi- nal cause. persists. to his he were protecting himself from something to his rear. the hand carried to the brow.192 MENTAL DISEASES As already stated. The painful feeling. suppressed. of another.

from more or marked however. realizing the possible legal conse- quences of his cealment. commonly . He may complain of head- ache. it is role. are usually perpetrated in such a . sometimes by certain words. Curiously enough. unusual quiet and If the patient strives to resist the impulse. while puberty is phenomena. act. gives is way to a feeling of relief the moment the impulse liberated. being established or near a menstrual epoch. not infrequently practices deception and conis Pyromania another remarkable form. the patient suffers distress. way as to lead to ready discovery though the patient. too.) is Sometimes the phobia presented Sometimes the fear and the tic exceedingly curious. is The origin of the impulse often difficult of explanation. The sight of the flames. occurring as closely Persons suffering from this form of the all disease will appropriate miscellaneous objects of kinds. valuable and valueless. while in the neurasthenic-neuropathic subject they are constantly given motor expression. palpitation of the heart as soon as the impulse satisfaction 13 is and difficult breathing. it not infrequently occurs in connection with sexual for instance. Possibly at times suppressed sexual excitement plays a vals and. (See Part III. such as 13. the sight of the it object and the uninhibited impulse to take associated phenomena. he experiences a sense of is and relief. The impulse occurs at variable inter- said. barns or other buildings. However. gratified. reserve. sometimes the symp- tom presents itself in the form of kleptomania.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 193 successfully and give no outward manifestation of their exist- ence. The patient may become nervous and anxious. Chapter I. Here the impulse is to set fire to houses. this distress. are excited by a certain number. more pro- nounced symptoms may make their appearance. objects useful and useless. thefts. The too. is preceded by depression. ject If in the neuropathic sub- an effort be less made to suppress them.

extraordinary efforts in helping to combat the flames. and to which aid. of melancholia-mania or of pare- and. Finally. but . and not frequently the patient attracts attention to himself by his activit}^ and. though infrequently a symptom not namely. effort to unpleasant the alcohol an undoubted The diagnosis depends. however. in the disorders met with in various other affections. manic-depressive insanity and in paresis. it is more frequent among is Dipsomania another condition commonly grouped with the it is neurasthenic-neuropathic disorders. French writers. the truth be finally may reveal that the commission of the act was attended by much cunning and direct premeditation. the act In the younger and more obviously defective may be much more simple and and may and be relatively easy of detection. In some cases. pyromania state that is more frequent German girls. at times. would enable us to make a differential diagnosis. of the characteristic features of the neuropathy underlying the special sjonptoms.194 MENTAL DISEASES in- attended by marked exhilaration and excitement. in dipsomania. There also. when he and entirely from alcoholic The history symptoms. suggestion and imitation also play a role. patients. upon the history and the is symptoms presented by the free patient at a period influence. is an obsession. on the other. a phobia. a different character. of course. it marked shrewdness and If from himself. effort Probably. on the one hand. At the subsequent exhibit investigation he may appear ability as a witness and may in diverting suspicion disclosed. repress is we have to do at times with the memories. however. which is uninhibited. is Further. here considered it Among has. is the drinking rarely continuous over a long period. sis. according to in boys. writers. find a ready explanation in the pleasure in which some children experience playing with fire and which others derive from the sight of flames.

In over more than 200 cases. upon a great height may experience an impulse We it commonly speak of such impulses as "irresistible. this the case as regards suicide is and homicide. at suicide are very rare. committed nor a it single The loss of inhibition is is not as great as seems. it is true. and yet the facts It show that there is here a great deal of exaggeration. cocain. or other drugs. of liquor his not matter much to him what kind alcohol serves he drinks. sometimes none whatever. would lead us to believe. the impulse is not carried out. The conditions met with in neuropathic-neurasthenic insanity are sometimes appealed to to explain the impulse to suicide and homicide. in If liquors it be not at hand. morphia.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 195 present only during relatively short spells. Some patients when they handle a powerful poison it. following the assertions of patients. or may be ether. too. and really successful suicide rarer The obsessions are much less irresistible than some authors. Janet has strongly insisted on this absence of the carrying out of the impulse. impulse to use Thus. Anything containing purpose. may suggest the either upon the patient himself or upon some one else. says so. but a clearly is marked. The truth is that the impulsive tendency quite constant. alcohol any form is taken. he did not observe a single crime suicide." but are they of really irresistible? his The patient. really irresistible impulse often wanting. the sight of a weapon it. the criminal impulse successfully combated by the . has long been is known that very especially frequently. it does During the attack. at least. the stronger the better. he did not observe a single real occurrence. in which criminal impulses were present. and patient. Attempts still. asserts own accord. and in the intervals the patient usually shows very few of the ear-marks of alcohoUsm. experience an impulse to swallow just as another standing to leap.

committed whether in by drowning. a minister unable at the given time is to ascend his pulpit. Seglas. it is While the latter the probable explanation. ible. if the latter were really irresist- would be ridiculously inadequate. Here the patient acts. it is a well-known fact that suicide among these patients does occur. effort. often simple. disturbed breathing. The fourth form of neurasthenic-neuropathic insanity which to consider is is we have As the insanity of deficient will. quite evident. it For instance. in a patient of Marc's was sufficient to tie the thumbs together with a ribbon to prevent the execution of the impulse to homicide. palpitation. abulia. pallor. such suicide in his severely from a suicide own The and patient suffered finally marked tic convulsif. never wise to dis- regard the statement of the patient that he feels that he must kill himself. He knows the act it. if persisted but is unable to force himself to do The in. it may serve to re-enforce the patient's . Such cases have been observed by and Raymond. is often accompanied by marked distress. which. his will power fails him. That the statements of the patient are commonly is quite exaggerated. The question always is arises such cases the suicide the result of an irresistible impulse or whether it is the attempt to put an end to the depression and despair caused possibility is by an intolerable situation. fails in Sometimes the act which the patient exceedingly simple. to be accomplished. such as rising from a his inertia performing is chair. the writer has had one experience. though this support may be exceedingly slight. unable to carry out certain. if Very frequently the patient can overcome little a bystander gives a support. affecting is in stage fright normal persons. and that they are not guileless. Notwithstanding. Pitres et Regis. Thus.196 MENTAL DISEASES Sometimes the patient makes use of means to prevent the carrying out of his act.

to write. and actually all upon hands and knees and attempted to crawl. to these different country was Beard. Prognosis. who drew attention at first described as so affections. obsessions. but he could not go forward in the direction of the hospital. to pass through a certain door. Course. he could made his start. finally considerable time was lost before he arriving within a few hundred feet to proceed. That the abulia is closely related to the symptom of indecision. but to no purpose. ever since the days of Esquirol. to perform a given act. — The various clinical forms in which the neurasthenic-neuroitself pathic group presents have been known for a long time. and entered a hos- pital in the city. he could turn and go back. is on the one hand. early by Morel. have made frequent contributions to the subject. One of my On patients wanted to go to a certain hospital in the suburbs.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 197 will-power sufficiently to enable him to accomplish the desired end. They were many clinical entities. and later by Magnan. suburban hospital had played a That the abulia may assume a great variety forms. kleptomania. demon- strated that fohe du doute and delire du toucher possessed . dipsoAttempts were to reconcile mania. among the earlier Ger- man and writers in our it was more it especially Westphal and Griesinger. can well be imagined. did so. such as an inability to speak. As he fell felt quite his he made a severe effort to go. on the other. Conclusion. quite clear. Subsequently it was revealed that a phobia role equal to of in regard to the his abulia. until Raymond. The French writers. delire the various phobias. and to the phobias. General Considerations. made forms. and kindred affections. however. and reduce to a general proposition these apparently dissimilar It was not. he finally became unable go to either side. ill. of the hospital. He was finally obliged to turn back. in 1892. folic du toucher. among which may be mentioned du doute.

sometimes there it is is an astonishing minutia noticeable. though long and perhaps cumbersome. though exceedingly It has also precise. It remains merely to add that in given cases. "soul-weakness" can hardly convey a definite if conception. in which even hallucinations cases. as a whole. applied to the group the expression neurasthenic-neuropathic insanity. neurasthenia is That ordinary closely related to these affections has. the name of "psychasthenia. and we render the term into ''mind or mental weakness" I it embraces far more than can possibly be intended. Memory exceedingly of well preserved. underlying condition. the exhaustion which complicates the neuropathy may become so profound as to lead to states of actual confusion. been abundantly demonstrated in the preceding pages. absolutely preserved. that the memory. because. though rarely. have for years. He showed various symptoms which characterize this or that form were only the expression of a deeper. That clinical must also be accepted as a without saying. is a little slow in its operations. it at least expresses exactly what is found. the underlying neuropathy fact goes. of embracing the apparently that the separate forms in one clinical conception.198 MENTAL DISEASES psychologically identical characters that a real advance was made. Janet gave to the group." a term which must be regarded as rather unfortunate. The pasometimes tients are. been shown by Janet and others that the reaction is time in general greater than in normal persons. consciousness is In the vast majority of however. for the most part. is may make their appearance. detail recalled. In its way Janet's generalization was as brilliant as that of Kraepelin's in another field. I think. intelligent. therefore. but entire it is to Janet that the credit is due all of bringing the group under one caption. namely. neuropathy plus nervous exhaustion. endowed with unusual sometimes . sometimes they are artistic. ability. however. I believe.

because of the and to keep up sustained mental effort for any length of time —the ideas lack definiteness is and precision. in fact. In the less unfavorable cases." as were. in a smaller number it yields to appropriate treatment. in their full intensity. The patient tends to wander from his subject. Janet has given to this symptom the name of 'Teclipse mentale. of all the distressing symptoms Neurasthenic-neuropathic mental disease persists in some cases indefinitely. by reason haustion and the inherent neuropathy inability to concentrate the attention — that is. the course of the affection it is is but not uniform.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS of reasoning 199 literary. ominous characterized in their import. established. fre- and there are times when the attacks are pronounced and quent. the indecision. notwithstanding there are is moments when the quiet interrupted by brief slight recurrences of symptoms. becomes vague and uncertain. so pronounced that at certain This condition sometimes moments the patient seems to it have an actual suspension of thought. the patient passing through a long series of periods of comparative quiet and comparative disturbance. an "absence. Sometimes these peri- ods of calm last for months. The power and the judgment present of the ex- no noticeable abnormality. There are times slightly when the symptoms are in abeyance or but marked. and in a still smaller it number ceases spontaneously. The active periods are by a return of the phobia. sometimes for several years. the general or fundamental of the affection. are present." Having once been essentially chronic. and during their continuance the patient successfully may follow— and and even — his avocation. already fully considered. However. symptoms but the special symptoms are lacking. In the most unfavorable cases remains stationary. a treatment combining both the principles of the rest cure and . During the quiet periods.

as neuropathy. e. it is necessary to call to following important First. unusual shjniess. the law lead to trial may more intervene and may and imprisonment. of however. i. kleptomania and pyromania. or. even after symptoms disappeared spontaneously and did the lapse of years. In two my patients. facts.200 of psychotherapy to the to MENTAL DISEASES may bring about a sufficient approximation his occupation normal to permit the patient to follow his social obligations. very infrequent. the not. the psychasthenias. in order that we may view mind the the neurasthenic- neuropathic disorders. a confusion some- times marked and accompanied by hallucinations. they do occur. mercifully. both of them typical cases of agoraphobia. too. in which the impulse leads to criminal acts. diffidence or other peculiarities in the ancestry. that such a step sion may be advisable. and meet it is possible in some cases to bring about a practical recovery. it is a not infrequent experience to receive an account of nervousness. There are becomes so fixed cases. the trained observer is still In such recoveries. recur.. in for instance. at times of symptoms similar to . In conclusion. They is are commonly so lucid It is and intelligent that commitment out of the question. In such in- in a sanitorium or an asylum offers the only alter- In cases. too. in their proper perspective. to institutional restraint. ever. or in which the symptoms are of such a character as to make impossible or impracticable the continued care of the patient in his stances native. in which the obses- and dominant as to rule mercilessly every waking moment of the sufferer. only in the small number of cases in which the exhaustion be- comes so grave as to lead to mental confusion. It is a fact worthy of note that these patients rarely form subjects for asylum commitment. life own home. Cases that cease spontaneously already indicated. how- able to detect the underlying are.

that psychasthenics should be grouped among the biologically defective. feeble-mindedness and alcoholism. it is a striking the significance of which is unmistakable.GROUP IV —THE NEURASTHENIC-NEUROPATHIC DISORDERS 201 those presented by the patient. and at others. Secondly. the conclusion has much to justify it. with in Finally. fact. . are met the patients with suggestive frequency. though usually not pronounced. of more pronounced nervous disorders. stigmata of arrest and deviation. On the whole. especially in the graver forms. such as epilepsy. that are also manj'.of the symptoms presented by psychasthenics found in institutions for feeble-minded children.

i. a delirium. in dementia we deal with changes in the quantity of mind. it other mental disease. melanchoUa and mania. a confusion or a stupor. such as extensive apoplexies ings.. As just stated. It is may . of disease of the vessels and membranes. and changes in the quality of mental action. is and imbecility. As we have may follow one of the affections of the first group. there is a mental loss. All of the other mental thus far studied present symptoms which imply feeling. remains to consider dementia. follow one of the manic-depressive group. changes in the manner of thinking. dementia of two kinds. e. though this is infrequent. though this rare we may recall. A secondary dementia a mental loss which consequent upon or terminal to some seen. and the neurasthenic-neuropathic insanities. such disease may of senile changes. acting. or of those is and soften- met with is in paresis. this is a different condition from the deficiency of arrested morphologic development. that our study of the fundamental forms shall be complete. or of other gross lesions. mind which accompanies such as we find in idiocy loss.CHAPTER VII GROUP V—THE DEMENTIAS In the preceding pages we have considered dehrium. Dementia is an acquired mental Again. however. confusion and stupor. that 202 it is every now and then met with after a pro- . the heboid-paranoid In order it group. loss that ensues Primary dementia is a mental upon destructive be the outcome disease of the brain tissue. Dementia implies mental affections loss. primary and secondary.

forgets the occurrences of the . indeed. (See Part II. practically unknown sanity. e. become slow. quite common it is as the or terminal state of the forms of the heboid-paranoid Finally. He becomes he loses and misplaces objects. and requires a much longer period time in which to accomplish a given task. hallucinatory. as a consequence of neurasthenic-neuropathic in- Primary dementia is best illustrated by the symptoms met some persons as with in the simple mental loss that ensues in they advance in years. especially this requires much accuracy or much precision of movement. To the symptoms of this simple form we will now turn our attention. to do his work as well as formerly.GROUP V —THE DEMENTIAS It is 203 longed melancholia of middle final life. so gradually that those about the patient fail to recognize it until of it is already somewhat marked. i. Chap- An adequate conception of the symptoms of this simple study of all mental loss renders the other forms of dementia much easier. senile dementia of the simple form. not as good a piece of work as before. dementia praecox and paranoia.) for another chapter. reserving the study of the confused. Likewise his statements or his business dealings lack their former clearness and correctness. longer uses of his tools as skilfully. He no latter. and paranoid forms ter II. impaired.. evident that his Early in the case becomes forgetful. Soon he is no longer able to discharge his duties. The mental operations the patient ideas. he quently if is compelled to abandon the task altogether. and he begins to His judgment also becomes in keeping his acit make mistakes counts and in simple additions. and he has difficulty in taking in new he becomes unable to learn new procedures. Simple senile dementia begins gradually. is The when comfre- pleted. to adapt himself to new conditions. memory is affected. group.

both from loss of memory for words and from feebleness of thought. Niceties of sentiment and feeling. foreign languages. by little the defects of memory middle grow deeper. or of his tient forgets the number of his children or their perhaps the fact that his wife. or this or that family. wanders from his subject. irritable. after a becomes more general. on the other hand. check or perhaps sign his name to some paper how- . he becomes ties indifferent to his dress. The panames. of the fade. Things that he has been in the habit of doing repeatedly for many years he may. often he eats indish.204 MENTAL DISEASES of the day and day before. His speech becomes incoherent. the esthetic sense. soil his In eating he begins to scatter his food. begin to disappear. forgets his engagements. not infrequently he becomes garrulous. frequently repeats himself. clothing. ually. attainments of various kinds are lost. with little will. differently the food that happens to be in the nearest He is not much concerned with the events of his household. At first the impairment of while it memory relates to recent events. Various forms of acquired knowledge. Thus. he may be able to endorse a of which. continue to do fairly well and for a long time. he may be very cross and of Soon he becomes incapable mental or physical. He is credulous. and with greatly impaired self-control. forgets the point of what he intended to say. notwithstanding. but those period of life. not only recent events. Sometimes he forgets that he has already attended to a given matter. in company repeats the same stories. Little any serious or sustained work. member has his been dead many ideas years. forgets the ordinary proprie- both of speech and conduct. he gives a clerk the same instructions over again. Grad- more fundamental memories also disappear. childish. The patient becomes and language puerile. He loses his habits of neatness.

To who have no immediate relations or dealings with the patient he may even present the appearance of mental integrity. largely depends ceives. g. sometimes for several years. After a while there is loss of control over the sphinc- gradually the patient begins to take food with difficulty. For an account of other forms is of senile dementia. e. serenity. the emotional indifference. the reader referred to Part II. and even of thoughtfulness. and Senile finally dies of a bed-sore live life or some visceral complication. fat. flesh.. many dements The patient . Indeed. grow ters. the general apathy..— GROUP V ever. the intellectual void. . certain games of cards. A man in this may also play a game which he has played a great life. he loses becomes bed-ridden. The length of upon the personal care which the patient re- and e. may eat excessively. and for a long time the bodily nutrition may be well preserved indeed. during his those checkers. it is remarkable how long the purely organic func- tions digestion and circulation —may survive the dis- integration of the mind. he —THE DEMENTIAS 205 condeal dition may have very little knowledge. Chapter II. of placidity. often give the appearance of calm. g. dements sometimes a long time.

first. if present. insanities. therefore. confusion. . and. gross and malignant.PART II CHAPTER I THE CLINICAL FORMS OF MENTAL DISEASE RELATED TO THE SOMATIC AFFECTIONS In the preceding pages we have found that of the various groups of mental diseases. The The 206 Visceral Diseases. are merely at- tendant phenomena. in order to avoid unnecessary repetition. delirium. Parturition. comprising and stupor. the manic- depressive. the fifth. —are closely related somatic the mental symptoms are the direct outgrowth the bodily affection. Intoxications. will In the present chapter. Diseases of the Nervous System. of i. the characteristic and distinguishing features only of the various special forms will be here considered. confusion. two—namely. the heboid-paranoid. and to some extent mth dementia. we have to deal largely with delirium. and stupor. As these forms have al- ready been sufficiently considered. of (3) (4) (5) (6) The Disorders Metabolism. the Puerperium.. and Lactation. In the other groups. while the somatic symptoms. The various somatic affections are conveniently treated under the following heads: (1) (2) The The Infectious Diseases. the and neurasthenic-neuropathic first in mental symptoms are clearly the import- ance. and the comprising the to various forms of dementia disease. Pregnancy. e.

and yet soon . description. such a phobia appears only in a predis(See p. Syphilis. and the patient may give himself up to various nosophobic ideas. The psychic shock of the discovery of having acquired so terrible a disease may also play a role. whether the pneumonia. though brief. hypochondriasis. no evidence of their having acquired fear. tuberculosis. and also the delirium. Among these are syphilis. confusion and stupor of met with during the period period. hysteric symptoms may complicate the picture. in given cases. Mental symptoms during the primary stage are infrequent. 182. Certain of the infecclinical pic- however. 207 THE INFECTIONS The mental diseases which occur during or follow the acute infectious diseases have already been considered in detail in Part I. Sometimes persons and who have exposed themselves though there is to the risk of infection. is When occurring it often intense and persistent. influenza. syphilis. marked as- thenia. may develop a true special a sjrphilo- Of course. and. begin to worry and phobia. differ but little. but fails to be reassured. syphilitic infection ^The mental phenomena of may be divided into those of the primary. Chapter III. The patient wanders from physician to physician. merit a special. tions. Each time after leaving the examination results negatively. and pellagra. dizziness. However. or the various exanthemata. headache and other pains. we may meet with insomnia. erysipelas. malaria. They include the symptomatic and febrile deliria met with in the period of invasion and in the course of these diseases.) posed neuropathic subject. the secondary. because of the peculiarities of the ture.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 1. septicemia. depression. convalescence or postfebrile The symptom-groups presented infection be typhoid fever. and the tertiary stage.

in some cases. heaviness and stupor tressing may be met with. The mental affections which occur during the more advanced secondary period and in the tertiary periods partake more or less of loss of function. especially in tuberculosis of the lungs. —The recognition by the patient of the gives rise to anticipations. there a remark- . caution. a loss dependent upon organic changes. sometimes of. considered in the section on diseases of the nervous system. therefore. perhaps he has syphihs after again the weary pilgrimage to another physician's all. toward evening a confusion. the mental offer disorders of the primary and early secondary stage a favorable prognosis. the patient giving way more to gloomy thoughts and At other is times. should be exercised in cases in which previous nervous ill-health or a bad heredity complicates the picture. However. or. dreams are complained That. Mental symptoms are sometimes. at other times deUrium. office undertaken. hypochondriasis a marked and nosophobia. in a neuropathic quite severe. the symptoms presented may be hardly be added. These affections are. often he tries to see the doctor after dark. Often he tries to get an appointment with the doctor when no other patients are waiting. rarely are these symptoms pronounced.208 MENTAL DISEASES the physician the torturing doubt returns. marked excitement. so that grace. no one may know of his dis- How much more may chstressing is still the situation may become when such a phobia infection superimposed upon an actual well be imagined. They are toxic in their nalittle There may be. ture. Tuberculosis. need subject. met with during the secondary stage. on the other dis- hand. the doctor may and is have been mistaken. exist- ence of tuberculosis not infrequently depression. however. though infrequently. On the whole.

him physical Sometimes he will over-exert at other times he will drink to excess. —Malaria. believes that he is The is patient constantly getting better. as in miliary tuberculosis. the added symptoms Malaria. less However. when gross membranes is present. that something trust is is being tampered this dis- being put into it it. even sexual excitation If may be observed. That mental disorders in tuberculosis are more marked in predis- posed individuals. At times so great that leads to a refusal of food. uncommon is experience for the consumptive to believe that his food with.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 209 able and illusory sense of well-being. to which are added very frequently suspicions and even It is ideas of persecution. and the delirium may Confusion is by no means a rare accompaniment of tuber- culosis of the lungs. is so pronounced as to lead the patient into what excesses. and sometimes maintains this hopeful attitude up to the very hour of death. more frequently they accompany the appearance of the physical signs or follow the full develop- ment of the latter. ventitious infection from cavities also occur. is only infre- quently accompanied by mental disorders. there are. there of a may of course be delirium. invasion of the Finally. doubt- owing to the intensity of the invasion. At times the euphoria are for himself. or if in the course pulmonary phthisis there be a febrile rise or possibly adlike. he scouts the idea of dying. a euphoria. sometimes mental symptoms antedate the frank expression of lesions. the tuberculous infection be acute and febrile. to the neuropathy of the patient. of tuberculous meningitis. in individuals of a neuropathic make-up and heredity. The confusion not an is accompanied by depres- sion. that he going to get well. of course. or to other and as yet 14 unknown adventitious . as ordinarily met with. need hardly be emphasized.

how- ever. doubtless the exhaustion of the patient. may be unaccompanied by fever. At times this stupor is complicated convulsions. How- ever. times. in addition to marked exhaustion and hebetude. when the malarial attack is severe. Delirium sometimes however. nervous symptoms may be present. they sometimes persist after the malaria has been ap- parently successfully treated. toxemia and inherent neuropathy. confusion though they are not usually prominent. — Mental symptoms play a very frequent and often a very prominent part in pellagra. as a rule. delirium. been spoken of as malarial paresis. this Again. The by confusion is. Pellagra. a degree of dementia makes its appearance. this dementia has.210 MENTAL DISEASES factors. varying degree. the result of other infectious pro- cesses. confusion may make appear- Like the confusion. sometimes epileptiform. or has been comits by grave exhaustion. it may come on may be after the febrile attacks have passed away or in the intervals of the latter. a mild may At be noted. This fact acquires added . or stupor may manifest themselves in may accompany the febrile may precede the latter. though improperly. also. In the last mentioned instances. very profound. closely linked with the prognosis of the malaria itself. In chronic malaria. and may constitute the only or principal feature. severe and persistent. plicated ance. is quite rare. at other times tetanoid in character. and most frequently deepens into stupor. confusion. Occasionally it stage. of course. there exacerbations of the confusion amount- ing to delirium during the recurrences of temperature. The occurrence of such seizures is usually indi- cative of a very grave degree of poisoning. play here a role. an intermittent delirium may be noted. This confusion is accompanied by depression. The prognosis of malarial mental disorders is.

The hallucinations are usually quite active and and visual. possibly the death by water has in the origin endeavor of the patient to seek relief from the burning lesions sensations caused skin. by the erythema and other of the Rheumatic Fever. from hallucinations frequently both of hearing and of At times the confusion deepens marked and It is into stupor. confusion and stupor. Delirium and active confusion with hallucinations are quite common. its may present. — Rheumatic period. As in the other infections. disturbances of the digestive of infection companiments tract of the and other evidences and toxemia. comes on in the postfebrile or convalescent period of the disease. fever. The prognosis of the mental symptoms on the whole. stuporous. is delirium in active febrile Rarely this delirium frequently very and persistent. established. the mental symptoms belong to the group of delirium. as well known. More a long-continued confusion its with painful hallucinations and delusions makes this disturbance appearance. The patient is dull and heavy.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 211 importance when we realize that the disease has become in- creasingly frequent of late in the southern of the United States. and suffers vision. less active.) It may last a number of weeks. are both auditory clinical In its general symptoms and character the picture does not differ from that of ordinary confusion. which must be classed is among the infectious diseases. In one case under the writer's observation the patient was for a time is. and western parts Mental symptoms are the usual acerythema. In other cases a is persistent mental loss. a dementia. often mis- called melancholia. it is When the confusion is accompanied by severe depression. (See Part I. As might be expected. Chapter III. . quite favorable. important to add that suicide by drowning occurs in quite its a number of cases.

exceedingly slight. the neuropathy is Sometimes find in the inherited. in so is upon the nervous system its effects concerned. delirium. sense. may. are those of depression loss. e. stupor. undoubtedly plays a role both in the feebleness resistance and in the production of the alcoholic habit. or it may be of actual psychoses. a neurasthenia or a psychasthenia. confusion. on the other. of depression. the clinical pictures. i. by the difference in individuals as regards of resistance to its action The degree may. on the one hand. details. we learn that certain causes predispose to excessive use. of neurasthenia.. delirium.. e. however. When we approach the subject of the first. the action of the different poisons upon the cortex the same. The inherit- ance of ready exhaustion. or all of these causes variously combined. hausting chronic overwork and privation. Sometimes the habit has its origin . ALCOHOLISM AND THE ALCOHOLIC INSANITIES Alcohol.212 2. susceptibility. effects of alcohol. the most widely used of far as its action all the poisons. though fundamental characters resembles every other. and. In general terms. Feebleness of resistance may be due to a neuropathy. be enormous. of a neuropathic make- up of generally. i. we are impressed. Among the causes leading to an acquired neuropathy are exillness. MENTAL DISEASES THE INTOXICATIONS In a is The mental disorders resulting from the various forms of intoxication bear a general resemblance to each other. its Second. differ widely in their Each form of intoxication in its is distinguished by its it own special features. and dementia. and groups. Quite commonly we family histories of alcoholics a record of alcoholism. be taken as a type. and mental the dis- orders which it produces like those first which follow the infections fifth are classifiable under the confusion. of function.

but that a pre-existing or inherited neuropathy exercises a powerful influence in the production of alcoholic abuse. varying according to the individual. too. of alcohol. there and there is is at the same time a diminution an increased elimination of impulses of various kinds. we know. again.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS in the unhappiness resulting in 213 from the patient finding himself an occupation or calling to which he is unsuited and in which he sees nothing but failure. large. In other cases. a hypomelanchoha with waves of variable duration and recurrences. especially the amount ingested has been noted that the individual has a difficulty both of is apprehension and comprehension. it is too. In many of the cases of so-called hereditary alcoholism. There . and this difficulty creasing one. the patient resorts to alcohol to aid him in suppressing a painful memory or to obscure the depressing facts of an existence alike intolerable and unchanging. the is neuropathy that inherited appears to be a manic-depressive psychosis. an in- The mental processes are distinctly retarded. Frequently. indefinitely. found to be noticeably lengthened. the common mode The habit as of acquisition is through social custom. and the drug appears to have a specific action If on the cortical neurones alike pleasurable and exciting. is ex- The phenomena amount of an ordinary attack of alcoholic intoxicaAfter a given tion clearly illustrate the action of the poison. thus often acquired in early and may persist. there of the habit of inhibition are potent factors. ceedingly probable. has first been ingested. if Very soon. there ensue tion. it is the reaction time be tested. the patient is clearly in a manic phase —a is hypomania mild in degree —in which the excitement and lack In other cases. which manifests itself more particularly by a hjrpo- melancholia. of inhibition. again. life. the general effects of stimula- The heart drives an increased itself amount of blood through the brain.

the action of an agent alike stimulating and depressing. incoordinated movements. suffers sooner or later The chronic alcoholic from a diminution of ability to work. He remains in his accustomed channels of thought and action. in addition. apprehension and comprehension become more and more obscured. . He is buoyant and happy. The above picture outlines. jests. the subject becomes talkastories. His mental horizon becomes narrowed and contracted. new methods. effects are short-lived The stimulating of and transient while the depression function is more lasting. tive. breaks into song. on the circulatory apparatus and of small doses on digestion. moves about. or maudlin characterize the picture. motor disturbances become more pronounced and exaggerated gestures. of course. as regards especially the physical functions. He no longer has the former capacity for continued applica- tion. of ideas with an increased flow of is motor elements. and. The more stimulating effects. but there can be no doubt that even small doses increase the difficulty of intellectual labor. language boastful.214 is MENTAL DISEASES ideas. cannot. tells becomes reminiscent. and the patient finally lapses into unconsciousness. the phrases become incoherent. The details. The mental action becomes more and more disturbed and retarded. profane. CHRONIC ALCOHOLISM The long-continued excessive use of alcohol leads to certain changes both mental and physical. gesticulates. vary greatly with the personality of the subject. obscene. sad and he is sexually excited. puns. the quality of his work shows unmistak- able deterioration. or. to take He also finds it difficult and later impossible new ideas. the words mere jargon. perhaps. rhymes. be questioned. or to learn up new subjects. in brief. also an increased flow of words. There for the patient is animated. tearful.

etc. Soon he develops ideas of being injured. sufferers im- They are not insane in the legal sense. not permit us to discuss these in detail. forgets readily. the vari- ous glands. no one need him. to dislike. he knows. sense of duty. The heart is . as is well visceral changes no less pronounced. for years. and obligation alike become blunted. may be. They involve the circulatory apparatus. or Love of wife. or. He invariably relatives own condition. The admonitions of finally is and friends are is misunderstood and drinking or that he resented. He loses his sense of the proprieties and decencies. and even persecuted by those about him.. others should mind their own business. is progressive. sense of injury grows more marked and it may assmne the form of veritable delusions. oppressed. In some cases the deterioration sometimes worse. is He forgets his fulfil engagements or is so intoxicated that he unable to them. this fact which renders the care of such patients one of extreme difficulty. and the patient may The remain in this condition. child. etc. and this mentia. sometimes better. thus be established. tell He is drinking just what is right. to neglect. the digestive tract. He is emotionally and unreliable. alike His memory and fails to realize judgment become impaired. by far the larger in a condition number of cases of chronic alcoholism remain of partial impairment only. irritable. It is merely the from a vicious habit. and are mentally preserved to such is a degree that their restraint on the ground of insanity possible. restless. annoyed. Frank mental disease may finally pass into may a true de- However. unduly interfered with. Shame. accompanied by Space will of chronic alcoholism are. it parent gives place to indifference. The psychic phenomena known. may even be complicated by hallucinations. and peripheral nerves.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 215 He his learns with difficulty. the brain. He denies that he drinking too much. this is the exception. The mental impairment becomes general.

That an alcoholic or neuropathic heredity preis. leg. alcoholic confusion. the pulse soft and compressible. The liver reveals cirrhosis in greater or less degree. . wasting of the muscles. fre- quently optic neuritis and atrophy. the peripheral vessels dilated. rheumatism. disposes to the attacks of course. are exceedingly vulnerable to shock. The He is complains of headache. peripheral There is usually also a more or less marked degree of amblyopia. sensation. especially in the mornings. also. fatty. dizziness. of the on the other hand. patient sleeps but little. erysipelas. alcoholic dementia. and a trauma. It known also that such persons become delirious rather readily are attacked when they by some infection. the picture is Not infrequently. alcoholic is the early morning vomiting of the chronic a familiar picture. is There chronic gastric catarrh.216 MENTAL DISEASES weak. a severe fall. complicated by epilepsy. readily dilated. as witness the lividity and chronic turgescence of the features of the chronic alcoholic. neuritis. there is also a nephritis more or less advanced. to be expected. may be the direct exciting cause. in which the usual greatly exceeded. amounts are An unwonted excess. such as a broken sudden fatigue. such as pneumonia. will first It is to alcoholic delirium that we turn our attention. may prove an exciting cause. of frank The forms mental disease which result from alcohol consist of alcoholic delirium (delirium tremens). sudden is fright. pain. ALCOHOLIC DELIRIUM (Delirium Tremens) Alcoholic delirium ordinarily occurs in a person already addicted to alcohol. also. Alcoholic subjects. weakness of the blunting of legs. the sudden withdrawal stimulant accustomed may lead directly to the outbreak of symptoms. there tremor of the tongue and hands.

even his speech may to be disturbed. the delirium supervenes. 34. and appar- ently of the other senses.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 217 Frequently prodromata are observed extending over several days. sciousness is Con- in such case greatly obscured. sometimes a week or longer. The general physical condition is one of exhaustion. precordial distress. Finally. The patient sees serpents. are also present. He is has headache. Sometimes. and sleeplessness. tongue tremble more than ever. appear to be very vivid. but the hallucinations of vision are very numerous. the patient has numerous illusions of the persons and objects about him which add to his terror. It is exceedingly active. This delirium presents the the dehria (see pp. Sleep is practically aboHshed unless too. depressed. muscular twitchings or frank convulsive seizures are added to the picture. while the delusive ideas. tongue. and fully justify the expression of "the horrors" often applied is by lay persons to the condition. His hands. struggles with or tries to escape from his ene- mies. characterized symptom group common all of is et seq. A coarse tremor involves not only the face. he seems to be entirely oblivious to his environment. and by the fact that hallucinations of vision are ex- ceedingly prominent. and his dislips. tures. but also the limbs and trunk. The confusion is pro- found.). When turbed his sleep does occur for short periods only. secured by medicinal means. The patient very restless. are equally terrible and distressing. starting at the least sound. by dreams and nightmares. and nervous. The auditory hallucinations are alike painful. Sometimes. as betrayed by the speech and action of the patient. terrifying. it is dizziness. The patient is irritable. at other times the patient can be recalled to himself for short periods of time and by persistent effort. and phantastic. again. and hands. Hallucinations of hearing. frightful crea- ominous and threatening. The face .

the lips with sordes. ALCOHOLIC CONFUSION (Alcoholic Confusional Insanity) Alcoholic confusion in the may present itself in two forms: first. fusion In other cases. from pneumonia. and sometimes is irregular. The first form may have its origin in an attack of delirium tremens which has not entirely subsided. or pneumonia. Sometimes the active delirium grows but the attack does not disappear. The temperature normal unless complications. again. The great majority of cases recover. such as bronchitis. or from failure of the overtaxed and dilated heart. are present. Not infrequently the case when the patient has suffered from repeated attacks of alcoholic delirium. the tongue heavily coated. nephritis. though now and then death occurs from exhaustion. the heart's action weak.. second. pulse is The body feeble. makes its appearance without a preceding delirium thus a chronic alcoholic suffers more than usually from headaches. of an attack of delirium tremens may be very twenty-four to forty-eight hours. g. and which has passed into a this is more or less persistent confusion. is is covered with a sticky sweat.218 is MENTAL DISEASES and teeth covered the relaxed. and sometimes persists in a active form for a after a week or more. form of a confusion not differing in its symptoms from that of confusion in general. it e. the con. more frequently less extends over several days. Not infrequently it subsides less sound sleep. The duration short. and. in a form in which the delusions assume a paranoid character. The urine is usually much diminished in amount and concentrated. more than usually from insomnia. and the patient passes into a more or less prolonged period of confusion. small. He is more irritable than . accelerated. from nephritis.

and filled in apparently there are gross lacunar defects which are automatically and spontaneously by the patient. Gradually. good. it finally subsides. alcoholic changes in the tissues is The presence here a factor of moment. it is The visual hallucinations may less prominent. the audiare. tory hallucinations which are especially marked. dition is This con- not necessarily associated with multiple neuritis. hallucinations make The be appearance and with is them terrifying delusions. the recovery from the attack all may be remarkably well. and mental operations are more difficult. less Occasionally terminates in a more or in the marked dementia. as in the delirimn. 219 his he is more nervous." MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS before. painful They and and distressing. especially younger in- dividuals. and depressed. and if the patient relatively young. the patient becoming to intents and purposes The is prognosis of an attack of alcoholic confusional insanity in proportion to the degree bad and duration of the preceding of chronic alcoholism and the age of the patient. The confusion form gradually becomes less active persists in a subacute for a long time. fearful. though it leaves the patient quite frequently with some mental' impairment. In connection with alcoholic multiple neuritis. Korsakow many years ago described a condition of confusion which was characterized. though sometheir times rapidly. has not yet attained middle age or the senile period. usually for many months. but . However. picture presented that of an active confusion which never attains the height of a delirium. the degree of recovery that is may ensue sometimes very great. it As a rule. If the preceding alcohohsm has not been of long duration. There is here a general impairment of memory. especially by fictitious memories. if tissue changes is still have not yet become established. by a marked all tendency to the fabrication of events and occurrences of kinds.

speak of holes in the wall. are opposed to him. The patient may. is e. is poison in his food. danger here also of confusing with alcoholism a paranoia in which has existed previously. . post-alcoholic. there is Again. taste. the patient suffering from chronic alcohohsm not in- frequently develops a sense of injury. i. At the same time. smell. chide. The patient suffers from numerous hallucinations of hearing. in other cases it occurs after alcoholic for been established it some time. Finally. ALCOHOLIC PARANOIA As already pointed out in the consideration of chronic alco- holism. however. and which the picture pre- sented by the paranoiac has been modified by a subsequently acquired alcoholism. stenches are in some foul and way put into his room. are unfriendly.. e. no good a toxic. true persecutory ideas is may develop and It is not infrequently the picture of a paranoia presented. may The so-called Korsa- kow's psychosis may have its origin in the course of it an ordinary alcohohc confusion. that poisonous gases. reason for regarding other than an alcoholic. confusion. as in ordinary paranoia. of the house being wired. in a patient who al- ready has the paranoiac make-up or constitution. of his being annoyed and persecuted in various ways. There i. a feeling that the persons who are about him and who quite naturally admonish.. Quite frequently he believes that there smells. Under any circumstances the paranoid is nature of the symptoms very striking. de- lusions of persecution make their appearance. and try to influence or restrain him. existed for neuritis has Frequently occurs after the latter has some time. vision. exceedingly probable. that a paranoia does not de- velop save in a predisposed subject. and of bodily and visceral sensations.220 MENTAL DISEASES exist in the absence of the latter.

quently. indeed. he combines this idea with the belief that she trying to get rid of him and is putting poison in his food. when met with. the consequences of which may only add to the misery and unhappiness of a situation difficult to bear. and which. upon some pretext or other. The truth probably lies in the fact. Indeed. the wife. less frequently by name or other The frequency of the delusion of marital infideHty its is such as to suggest that there are special reasons for appearance.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS There is 221 one delusion. hardly surprising. He commonly speaks of them as "men. that occurs in alcoholic is paranoia with great frequency. that the patient sooner or Freis later conceives the idea that his wife has other lovers. first. we must remember that the attitude of the wife. it and at times this conviction it is becomes so powerful that leads to homicide. It is and reproaches. He becomes both Further. and that delusion of marital infidelity. denies her husband. looked upon as of almost diagnostic import. however. bestialized and brutal. believes that his wife is is the Sooner or later the husband unfaithful. hardly received willingly by the wife. is the chronic alcoholic. His statements in this respect are usually such as to leave that he of taste. however." distinctive designation. too. and not the supposed paramour. and more or less incompetent. because of her constant remonstrances. which becomes of more marked in proportion to the degree and the duration indifferent the alcoholic poisoning. avoids an act. is already construed as inimical. the latter frequently. already In addition. therefore. who is slain. pleadings. that the alcohoUc suffers from a depression of his sexual function. the patient's notion as to the persons with whom his wife is having improper relations is usually very vague. is no doubt illusions suffering from marked hallucinations and Associated with these there may be vivid hallucina- .

He may see men hovering may hear their footsteps. under the bed and in the As in ordinary paranoia. way. however. the patient's orientation. that he is very able. the para- noid ideas and attitude persist. He may search for at night. . expansion in characteristic. As the case continues. that he portance. has As in Long had no access to alcohol. them closets. however. that he has never had a chance. do his ideas assume a definite form. is really a person of consequence and im- Rarely. He really conceives the idea that he has never been properly appreciated or understood. expansion may become manifest. of course greatly disturbed. ordinary paranoia. and in than the members of his family or those with whom he comes in immediate contact he may betray little of his really serious condition. as in ordinary paranoia. The physical signs. the withdrawal of alcohol not followed by the disappearance of the delusions. Again. as in the prison or the asylum. his bodily nutrition and he loses in weight. present the gross physical signs of alcoholism to the degree in which they are found in is other alcoholic patients. and the general health may of may im- prove under institution care. Later. alcoholic paranoia is On the whole. as already stated. and he talks freely and insistently of is His sleep fails. the latter are fixed and persistent. due to the chronic intoxication. his relations with others may be unimpaired. candle in hand. but.222 tions of sight MENTAL DISEASES and hearing. or consignals. course become less marked. after the patient. is neither marked nor The prognosis of an alcoholic paranoia very unfavorable. and frequently does not. cealed about the house or or messages. his general appreciation of his environment. the belief in the unfaithfulness of the wife and that she tried to poison him remains unshaken. reticence and his restraint give troubles. At the same time he may not.

and the absence of the physical signs of the Argyll-Robertson pupil. Incoherence. the loss of memory grows deeper. e. and. of the atactic speech. there is loss As in other of memory and an impairment The mental faculties generally. fluid A serological examination of the blood and cerebrospinal though the may also senile be made (see section on Paresis). As in dementia from other causes. hallucinations. The deterioration gradually becomes more and more pronounced. and. It was at one time the habit to speak loosely of alcoholic dementia as . Loss and loss of self-control are progressive. or. In practice but Httle difficulty is experienced. when occurring is in older individuals. the sense of shame. suffices. more or less 223 marked in degree. prising. as a rule. confusion. of the affections. of tremor of the lips and tongue. of inequality of pupils. the result of long-continued chronic alcoholism. If comes on in the course of chronic alcoholism progressive. finally. soils himself.— MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS ALCOHOLIC DEMENTIA Mental impairment. of dementia. complete the picture. may be. delusive ideas complicate the picture. already present in the chronic alcoholic. should suggest senile dementia. until of will is it involves all periods of the patient's life. of the to anomahes of the tendon reactions —serve make the distinction. it is more pronounced it is here. mindlessness. abundantly The distinction is from dementia and from dementia due to other causes again to be based upon the history and upon the very evident signs of alcoholism and associated visceral symptoms. or after a prolonged attack of alcoholic confusion. The patient indifferent to his person. blunting of the finer feeUngs.. stupor. after severe may be may ensue forms of the and repeated attacks of alcoholic delirium. of the proprieties. not sur- From paresis the history of the case i. clinical examination. paucity it and feebleness of thought. That this picture should suggest paresis.

therefore. cases in which permanent to the viscera. Sometimes this and may approximate the normal. again. but the expression justification. a feebleness of and inability for sustained In others. and is also true of the cases observed in private practice. to a persistence of auditory hallucinations. the lead insanities form but a small percentage. and it Nature is very is remarkable how great a degree of recovery in sometimes ensues an apparently hopeless case after the alcoIndeed it hol has been long discontinued. already pointed out. memory. of the cases of lead poisoning considered as a whole. misleading and has no A correct diagnosis is important. PLUMBISM AND THE INSANITIES DUE TO LEAD Chronic lead poisoning. damage has been done blood-vessels and especially to the and to the brain ensue and the de- and membranes of the brain tissue itself. a general identity of action affects the Lead poisoning organism as . It also a remarkable fact that. a persistent mental impairment. rare. Lead insanities are. and resemblances which they bear to the and because they is illustrate the general truth. that there of the various poisons. and. like alcoholic poisoning. perhaps. again. because alcoholic dementia presents in some cases a favorable prognosis. little or no improvement may mentia may persist in a profound degree until death. however. induces disfirst turbances of function belonging to the and fifth groups of our classification. They are very interesting. may be said in general that.224 MENTAL DISEASES is alcoholic paresis. there may be a tendency to mild confusion from slight ex- haustion. in other cases. In the unfavorable cases. Lead poisoning is not met with as frequently this is in the public clinics as formerly. if the visceral changes are not pronounced. because alco- of the analogies holic insanities. mental effort remain. kind. some degree of recovery is decided may usually be expected.

and there is then a symptom group presented suggesting a i. as clinical its is well known. flashes of light. in such cases as the writer has observed. however. slowness of and frightful dreams. but. that of lead paralysis with double wrist drop. peripheral tabes. 15 The restlessness very great and severe exhaus- . Cases with diffuse and general symptoms only are.. Tinnitus. and lead Occasionally the toxic effects remain general.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 225 a whole. delirium sets in and may be intense in degree. objects. exceedingly rare. cannot be excluded. The hal- lucinations are exceedingly painful and terrifying. are not attended by times a history of lead colic can be It would seem as though the insanity eral lead toxemia. its vessels and membranes. but does not usually attract attention. lead palsies and lead colic. lead rheumatism or arthralgia. it usually assumes well-marked colic. mental action. e. as in alcoholic delirium. or at least usually sought for. but they serve to accentuate the fact of the general toxic action of the lead. which may be very marked. an action which is probably present in the classical clinical is forms. Finally. marked insomnia. encephalopathy. in another case of general lead poisoning the patient presented a hysteroneurasthenic symptom-group with- out definite physical signs. namely. though someelicited. visual hallucinations pre- dominate. not Lead insanities. and. a widely diffused peripheral neuritis with changes in the optic nerves. one such case has been observed by the writer. that of de- As a rule. very curiously. lead forms. and depression also make their appearance. disorder most frequently observed is The mental lirium. it is preceded by headache. in a given case were the result of the gen- though a local effect upon the brain. The patient sees terrible and menacing forms and to delirium tremens of is is still The resemblance by the presence further increased tremor.

featured now and then by delirium. 226 tion MENTAL DISEASES may occur. There is grave a impairment of memory and of the other mental faculties.. the lead poisoning results in a dementia. of will-power. at times there are remissions followed in which the intoxication has not by recurrences. self-control. recovery ensues is in other cases a fatal termination not unusual. The symptom-group a more or less that of dementia ordinarily. and the query arises whether the visual hallucinations bear any relation to the changes in the optic nerve. also. progressive deterioration of habits and conduct. in which both auditory and visual hallucinations were prominent. that amaurosis not infrequently follows an attack of lead delirium. in which the history of delirious episodes and is epileptic seizures not infrequent. episodes of weakness. or epileptiform attacks. until a decided or profound mental loss is established. the delusions assumed a distinctly paranoid character. Chronic lead poisoning character. Sometimes stupor and coma supervene. . There was here a suggestive resemblance to alcoholic paranoia. Sometimes its progress interrupted. In cases been profound. In one instance observed by the writer. dementia may supervene upon an attack of lead delirium or may is follow a more or less prolonged and chronic lead poisoning. The urine is usually scanty and concentrated and may contain albumin. the patient was persecutory as regards his family and made charges against the chastity of his wife. rarely does is it extend over a week or two. may lead to symptoms less acute in There may be mental depression with mental confusion. their At times epileptiform convulsions make It is appearance. The delirium may last for several days. In another group of cases. this result followed in three of the cases under the writer's observation. Thus. rather suggestive. speech and thought. cases Such must be regarded as excessively rare.

the patient relief is one who has experienced the prompt and pleasurable jection of morphia. Ordinarily. them now and not Women suffering from pain at the menstrual epoch. as instanced by degeneration of the optic nerve. usually suffer very keenly. in the use of the drug for the relief of pain. If the poisoning if has been long continued. especially at is first. the prognosis is proportionately unfavorable. given by a hypodermic inis The physician sent for again and per- . and there be reason to think that organic changes. cannot do her work. may gradually get into the habit of using these medicines regularly at the menstrual periods. however. and thus gradually is the habit of taking laudanum or paregoric established. is recourse to surprising. we find in the prisons persons who have been opium smokers. and who. as just stated. the prognosis of lead dementia much more unfavorable than that of alcoholic dementia. MORPHINISM The in the habit of using opium or morphia has its origin mainly employment of the drug for the relief of pain. however. she feels weak. Much more frequently. In this respect it resembles alcohol. have supervened in the nerve-centers. and finding that a few drops of laudanum or a few teaspoonfuls of paregoric give relief. de- prived of the drug by reason of their confinement. or perhaps habitually. The and vicious practice of clinics opium smoking brings to our hospitals but few patients. and that some persons should have then. favorable provided the intoxication has not been too long continued. That laudanum or that paregoric will stop pain is known to every layman. little by little the the patient begins to use them also in the intervals on some pretext or other.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 227 Lead dementia offers in some cases a favorable prognosis. is On the whole. occasionally. the habit acquired. feels a craving for the drug. however.

His character undergoes marked deterioration. intellectual The memory likewise becomes impaired and the . We must remember that production in the normal individual there is little risk in the of a habit when the drug is administered by a physician. refuses to com- and insists that the pain. has The no de- normal inchvidual. his pain. nor does he hesitate to commit theft if it enable him to achieve this object. and frequently they do not know how it. and freely help themselves. is His emotions become blunted and there a loss of the sense of responsibility. hesitate to lie. morphia poisoning are both mental The patient betrays a loss of vigor. as in the case of alcohol. patients habit- ually understate it. his energy and aptiis His will-power lessened and in thoughts and acts he reveals indifference. ply. having been reheved of sire for a repetition of the dose. of chronic The symptoms and physical. be relieved by other means. especially by the he can secure a supply of his coveted stimulant. finally cautions the patient.228 haps repeatedly. It should be added that. He if does not latter to practice deception. his work. if present. but in dram bottles of the powder. In many pa- a frank neuropathy. much they take. and the dose is rapidly in- creased until very large amounts or may be taken—ten. Under these circumstances the patient frequently succeeds in securing a syringe and also a supply of the drug. very difficult to get accurate information as to the amounts. twelve It is more grains in the twenty-four hours. MENTAL DISEASES The latter. Sometimes they procure not in the form of tablets. knowing the danger of the for- mation of a habit. Tolerance is quickly established. an imhis pairment of the power to do tude alike are diminished. the formais tion of the habit greatly favored by the existence of depres- sion or of recurrent depressed mental tients there is states.

MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS faculties. If we examine the hypodermic skin closely. the patient from palpitation. The tongue is frequently is The appetite is greatly diminished. quite commonly he cannot is sleep until he has his morphia. sometimes they are exaggerated. The mouth and throat coated. torpor. at the same time the patient irritable. and dry. there is a more or less marked hyperesthesia of the skin of the extremities. . we often find numerous fine scars of injections. The extremities are cold. the Sometimes. not infrequently. his sleep is for a longer period than usual. as is 229 a whole. is There inertia and which may be very marked. is The super- fat disappears. constipation. are dry. relaxed. Some- times the patient describes paresthesias. When. There is marked tone. we handle the limbs of the patient. is Frequently. too. or furuncles may be noted. years. Digestion circulation delayed and there is marked cardiac suffers The is much depressed. especially is there a dislike for meats. asthenia is marked. much had impaired. especially during the nervous and excited periods. we note that he flinches. local suppuration from infected injections. betray a depression of function. together with tremor and loss of The reflexes betray no characteristic change. sometimes the scars of pustules. is There is a greatly diminished thirst and the urine much diminished in amount. sometimes they are diminished. especially during the intervals between the doses of it of his drug or when he has been deprived Finally. muscular weakness. and. the skin yellow. he hallucinatory while the sleep coming on. more rarely does the normal sensibility seem to be diminished. The ficial nutrition of the patient is greatly impaired. in making a physical examination. when the drug has been used for many appearance and the mental state suggest that of a person is who aging prematurely.

. actually being accomplished. complains of a sense of oppression. a diarrhea. either from some visceral complication. If the use of the drug continues for a long time. These vary greatly in accordance with the gradual or abrupt character of the withdrawal. complains perhaps of having caught cold. instead of an asthmatic attack. such as a gastro-intestinal disturbance. Involuntary movements of the legs and arms also appearance. and always accom- panied by more or insomnia. or respiratory tract.230 MENTAL DISEASES Menstruation may become scanty or may death be suspended. weakness and exhaustion may become profound and may ensue. it is tempts to pick up a glass of water decidedly. In addition to restlessness. this is make their At times in- merely due to restlessness. referable to a cold in the their appearance. Intention tremor the patient at- becomes evident. a dysentery. or. The patient also yawns a great deal or sneezes. by a Just as soon as the patient is amount given below that to which the its accustomed. the symptoms head or a spasmodic cough vesical may make Sometimes tenesmus is . declares himself dissatisfied with the treatment and insists upon going home. the limbs being thrown about the bed. it some infection of the may when be. from heart failure. in is The special point of importance to bear if mind is that they are never absent It withdrawal of the poison the custom of the writer. restlessness makes appearance. e. for instance. is This restlessness may become less very marked. noticed that he trembles all Sometimes. is for reasons which will soon become apparent. When. or perhaps has an attack of difficult respiration. simulating asthma. at other times distinct voluntary jerkings also make their appearance. to withdraw the progressive diminution of the dose falls drug gradually. the patient manifests signs of fear. i. Very interesting and very important symptoms ensue case of morphia habit in a the poison is withdrawn.

there are convulsive seizures. few hours. Occasionally serious attacks of heart failure are observed times. nations of hearing and sight. though rarely. There a sense of sinking and oppression in the epigastrium. vomiting. resulting The mental symptoms The from morphia withdrawal of a assume the form most frequently intensity of the very active confusion. . falls symptoms usually below that of a is delirium. A prompt recourse ment. together with distressing and fearful delusions. If the Palpitation of the heart may also be evident. there is serious danger of death. if the case be one of years' standing. moans or cries out. there appears. During the most disturbed period hallucinations of vision may be prominent.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 231 noted. The heart's cold. and. and. however. once estab- tend to persist. and very frequently gastric and abdominal pains. painful in character. accompanied by nausea. in physical signs. however. action becomes weak. patient cordia. make their appearance. to morphia will usually bring about an abate- many cases. Halluci- and very frequently becomes confused or delirious. a feeling of great weakness and fatigue. the pulse rapid. The mental symptoms sometimes arise when the morphia . is after a The patient unable to stand or to his move about. but later those of hearing predominate. and profuse diarrhea. with probable changes in the heart muscle and nerve-centers. a disappearance of the alarming if The mental symptoms. lished. He trembles is from exhaustion and body is bathed in sweat. somein- Not frequently the patient passes into a collapse. the extremities tient is The pa- greatly agitated and disturbed. or the may complain of fluttering sensations in the pre- withdrawal be abrupt and complete. Occasionally. the onset that of a de- lirium which soon passes into an active confusion.

probable that the nervous disturbances. can be explained on no other ground. the sweating can only be regarded as efforts Similarly. the delirium are the result of the now unopposed action of this antibody upon the nerve-centers. is and if the patient continues comfortable and in good sleeps well. is tolerance. often persist for a long time. especially if the depression produced by the vomiting and diarrhea be accompanied by mental confusion and delirium. spirits. of all that Unfortunately the mental symptoms. or relative immunity. in spite may be done. and may. their appearance. he It ob- taining the drug surreptitiously. the diarrhea. of these It stands is and intensity to the withdrawal to reason. but has. been too rapid. as a matter of necessity. it is on the part of nature at elimination. No picture is more alarming than that often presented by morphia patients in the stage of withdrawal. extremely itself. and is contented with his surroundings. Indeed. Hirschlaif has demonstrated the presence of such an antitoxic principle experimentally in animals. therefore. It is exceedingly probable that the long-continued ingestion of the morphia gradually results in the production of an antitoxin. that if none symptoms present. which at times ex- traordinary.232 MENTAL DISEASES withdrawal has not been complete and abrupt. that with the withdrawal of the morphia a definite group of symptoms must make its appearance. notwithstanding. It follows. of the accumulated antitoxin. and in exact proportion of the morphia. should be remembered that even under very gradual withdrawal some of the symp- toms mentioned above make indeed. so that little by little the patient becomes this more and more tolerant of the drug. It would seem that the symptoms drug are largely due to the arising during the withdrawal of the unantagonized action. the vomiting. become so marked as to necessitate for a time a return to a larger quantity of the drug. not only .

Morphia and users frequently learn that they can lessen the drowsiness somnolence of the morphia by taking cocain. may be by delirium those or confusion. solution. of using cocain is Another method quired is in which the habit ac- in connection with the use of morphia. first. they fade and disappear.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 233 for days but for many weeks. these sjonptom-groups again suggesting occurring in the course of alcoholism. Soon. In summing up the mental phenomena resulting from chronic morphia poisoning. diffused among the lower classses. and. he prefers to swallow some of the little later tries and a to procure the alkaloid in bulk. is now and then an patient learns indirect outgrowth of nasal The that the physician executes certain procedures. upon the nose The is application not only renders the is area to which the drug applied insensitive but also followed by a pleasurable sense of exhilaration. and generally by persons who other intoxicants. however. COCAINISM Cocainism surgery. we may say. that the latter leads to a mental enfeeblement somewhat resembling alcoholic dementia. probably through the action followed an antitoxin. Here it is not infrealso use quent to find it used. try to cut Some of them down the morphia by adding cocain. his may sucand may begin abuse of the drug by applying it with pledgets of cotton to the nose. performs various operations after its application. The patient ceed in securing some of the solution himself. however. strange as may especially in the tenderloin and slums. and second. . that of its withdrawal. A knowledge of the pleasurable effects of cocain is it widely seem. Eventually. and end by acquiring the cocain habit as well.

leaving the room and coming back. and conceals both drug and syringe most unexpected places. sitting down. a small rapid pulse. sweating. the patient commonly from hal- . and an indifference to obligations and responsibilities. a more or and will marked impairment of energy power. often. he talks incessantly. in the often successful. coldness of the feet. and in- The is patient is and agitated. suffers Under these circumstances. too. frequently he complains of tingling in the extremities or of ringing in the ears. a pleasurable Sooner or restlessness. Usually there is pallor of the face. a more or less persistent state of confusion —a confusional insanity —may become established. he gradually becomes unable to do impaired. is. more pronounced mental toxic states. lie. however. later. He cannot keep still. morphinist. hands and and occasional nausea. symptoms may. experiences an imperative need for sense of well-being. general efficiency becomes greatly reduced and finally When the drug has been taken in large quantities and for a long time. dilatation of the pupils. he is More alert than the morphinist. getting up. go to any extreme to obtain the drug. his memory become He weak and Like the easily angered. he After each successive dose the patient feels stimulated. In cases in which the habit has been as in the case of chronic alcohohsm less well established. there and morphinism. adopt any expedient.234 MENTAL DISEASES of a full dose of cocain consist especially in a in a sense of exhilaration restless The symptoms marked general excitement. Just as in the case of alcohol and morphia. unrehable and forgetful. this gives way As in the case of the other his poisons. going from one chair to another. as in other make their appearance. his is will- power and irritable. he always changing his position. The patient's lost. toxication. he will steal. to depression with activity. work. a lack of purpose and concentration.

Sometimes he believes that infested his body. Long-continued poisoning by cocain results in a more or less grave depression of nutrition. ringings. may consist of whistlings." Hallucination of sight. Each dose of cocain prevents sleeping. his bed are by fleas or some other insect. as in alcohoUsm. as already stated. liike the alcoholic. but the tactile hallucinations are the most prominent and striking. only after access to the drug has been cut off that the patient sleeps. The hallucinations of hearing cries. and. his room. However. There is tremor of the tongue. cardia or brings on a frank attack of palpitation with dyspnea and faintness. Exertion readily increases the tachy- dilatation of the pupils. so common this symptom that sometimes spoken of as "having the cocain bug. unlike the alcohoKc. the patient may see curious ani- mals. and then he may sleep excessively. His reflexes are usually somewhat exag- gerated.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 235 lucinations. sticking. Like the alcoholic. crawHng. shapes and phantasms which agitate and move before him. of taste and smell may also be present in greater or less degree. especially of the extremities. inarticulate or words. or picking is them it off his is person. he is sexually indifferent and impaired. . it. more particularly from hallucinations referred to the surface of the skin. He is continually wiping. The mental weakness may until a condition analogous become more and more pronounced. is The sallow. he may is evolve the de- lusion of marital infidelity. The patient and his looks aged and His face is expressionless movements betray his bodily weakness. of hearing. Associated with his painful hallucinations. the patient may but. he is not actively disturbed by His sleep his much it is broken. brushing. and biting sensations. Indeed. entertain and de- pressive delusions. He complains of itching. general nutrition poor.

which the writer saw a number of times first in consultation. then attempt to lessen the amount of alcohol required or to combat the in- somnia of alcoholism by taking morphia. and observing the symptoms. finally. they resort to cocain to combat or to aid in concealing the effects of the of the triple habit. the patient renewing the knowledge or consent. confirmed mental symptoms are persist for a variable period after present. scription without the physician's Little by little the patient becomes accustomed to the drug. like morphinism. the truth can only be elicited by isolating him. there is here much less danger of inducing delirium and confusion than If in the case of morphia. the morphia. Usually the cocain can be withdrawn at once and without any risk. it Suffice it to say that. gradually became finally died of exhaustion. to a prescription frequently owes its inception pre- by a physician. Such persons usually begin by abusing alcohol. and Cases of such severity are. the exception. INTOXICATIONS BY CHLORAL AND OTHER DRUGS Chloral has been so largely displaced by the newer hypnotics that chloralism is now a very infrequent condition. passed through a typical confusion. and soon . Thus they become victims In such cases the symptoms of the three poisons are commingled in varying degree. preventing access to the poisons.236 to MENTAL DISEASES is and resembling alcoholic dementia established. more and more mindless. and the cocain habits. however. morphia. it is Quite commonly is found that the withdrawal of the cocain or less rapid amelioration followed by a more and recovery. One such case. these may the drug has been discontinued. however. As the patient's statements are unreliable. Not infrequently we meet with patients who are alike the victims of the alcoholic.

DISORDERS OF METABOLISM of metabolism. Some of the more recondite problems have already been discussed in connection with dementia prsecox (see p. and paraldehyd. diabetes. Among the drugs to be borne in mind are trional. confusion is. 106). each is. Other hypnotics may yield similar symptom-groups to those above described. p. attended by depres- and may superficially suggest melancholia. 3. Dyspnea. The application of general principles readily leads to a correct interpretation. three only will merit con- Of the disorders sideration here. ness. and obesity. They and are sometimes taken by alcoholics to combat insomnia. namely. and a as weakof manifested by loss will-power and failure memory. ness. or the patient may is be mildly confused. and there may be both visceral and auditory The sion. Other general disturbances of nutrition are considered in connection with diseases of the ductless glands and of other viscera.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 237 cannot sleep without it. It is a poison which is depressing to the heart and vasomotor apparatus. gout. as a rule. of course. is It cannot be claimed that the use of these drugs common. featured by its own special symptoms. hallucinations. 131) and with manic-depressive insanity (see . attacks dehrium may supervene which bear a marked resemblance to delirium tremens. In cases in which the poisoning of is more pronounced. Paraldehyd occa- sionally taken directly with the whisky. sulphonal. and among the symptoms likely to be In w^ell-established cases there are marked nervouscertain degree of mental of marked insomnia. not active. is may thus complicate the picture. general sense of weakness are present. vertigo. medinal. veronal.

The quiet. A mild and painful ideas. and lacks his former will-power. Thus. In the last-mentioned instance. and may be here briefly summarized. in the fully-developed period. the patient suffers from spells of drowsiness or frank attacks of somnolence. At first sight it may seem unscientific to attempt nature to correlate mental of phenomena with an affection. as is well known. sometimes of gradual. The clinical facts are well known. physical weakness. The quantity . there may be depression or unusual excitemental exhaustion. uncertain. in a certain number of diabetics. It is sometimes of sudden. with accentuation of sjrtnptoms.238 MENTAL DISEASES DIABETES Diabetes is a symptom group in which. but a delirium is rare. the ductless glands. with depressive ance. of urine ment and restlessness. sleeplessness. however. the pancreas. certain prodromal sjonptoms may be present. and dizziness. makes its appear- Often the mental condition resembles melanchoha and Occasional episodes of ideas of suicide are not infrequent. he becomes apathetic and indifferent. headache. or in the final stage of the affection. and the nervous system play a varied role. excitement. and easily disturbed. in the beginning. are present. Diabetic Coma. nervous and mental symptoms are definitely present. may be imperfectly enunciated and the gait and movements confusion. These may recur or may gradually or at once pass into stupor. and more frequently. A mental enfeeblement simulating a deSpeech mentia may become established. At other times. patient suffering from diabetes may become depressed. the which is itself as yet imperfectly understood. His capacity for intellectual labor diminishes. —Diabetic stupor or coma may appear at any time in the course of a diabetes. the so-called diabetic coma. evolution.

the sweetish odor of the breath . to say here. The patient lies extended and inert. however. If the attack is in from a few hours to three not severe the patient may re- cover. is The movements normal in number at first. to suffer from a recurrence. The attack begins quite frequently with nausea and vomiting and with a copious and watery diarrhea. his limbs relaxed. Pending the examination of the urine. by the examinaton of the urine. though infrequently. his pupils dilated. his face is pale. Soon the patient becomes quiet and soon he can no longer be roused and passes into a pro- found coma. only. cries. purposeless move- ments and torpid . agitation. We should remember. Sometimes there are of the abdominal pains accompanied by distension Usually there tion is is abdomen. For the condition of the urine. respira- a sweetish odor to the breath. The pulse regular. from alcoholic intoxication. perhaps re- peated. especially of B-oxybutyric acid. difficult. The onset of the coma may be preceded by a short period of excitement. that the examination of the urine reveals the presence of acetone bodies in decided amounts.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 239 for the twenty-four hours may. become diminished as the coma established. The temperature becomes subnormal and death ensues or four days. the reader Suffice it is referred to text- books upon internal medicine. and finally fatal. gestures. that in is some diabetics. in this connection. from apoplexies. and deep. is while the expiration sudden and short. and diabetic coma is to be distin- guished from attacks of uremia. Auscultation reveals no of respiration. though usually small and rapid. changes in the heart or lungs. incoherence. to which the coma is due. the inspiration is long. is The embarrassed. during this period. be decidedly diminished. the attack complicated by uremia.

and not infrequently she will quarrel with her neighbors in the wards to such an extent that isolation becomes imperative. The fre- mental disturbances of gout manifest themselves most quently in an active delirium. negroes were frequent. and other distressing sounds. auditory hallucinations consis-ted of threatening voices. of The attack about five lasted. relation now and then met with. they are now and then met with in adiposis dolorosa. The opposition may enrage the patient. may suggest the nature of GOUT Mental symptoms the they are result of gout are very rare. in addition. However. One such patient under the consisted apparently of writer's care presented vivid hallucinations of both sight and hearing. Sometimes she thinks that the other . In this affection a cerebral asthenia or ready cerebral exhaustion is rarely absent. usually of short duration and of irregular recurrence. great irritability. ordinarily. which the adiposity related to disease of the internal secre- tions. and especially in cases somnolence in may make is their appearance. The delusions were corre- spondingly painful. this is at times so great as to be attended by a least change in character and disposition.240 MENTAL DISEASES of the breathing and the character the attack. Many patients present. while the cries. does not present mental sjTuptoms of consequence. Less often the attack consists of an active and prolonged confusion. and appear to bear a to the sudden recession of local gouty manifestations. ADIPOSIS Adiposis. apathy. for months. DeHrious and confused states are infrequent. inertia. with varying periods improvement. However. mental weakness. The visual hallucinations dark objects and images. Notwith- standing.

This exists in the pre-existing neuropathy Surely. some special factor. the man in whom such symptoms do appear must vulnerable. One of Eshner's patients was disturbed mentally to such an extent as to necessitate her commitment to an asylum. states. toxic substances are in. betrays no mental symptoms in response to the toxemia. other things equal. much common. and the truth is at once apparent that some added. At times. as in Bright's disease. who is ill for months and years with Bright's disease. and these demand a brief consideration. As in the case of other poisons acting upon the nervous confusion. less There are. this is and stupor. in Bright's disease. occurring both in Bright's disease and other visceral affections. toxic substances foreign to the organism are produced and find an entrance into the blood. Giudice- andrea has noted delusions of persecution and a true dementia. unusually the case. at other times.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 241 patients and the nurses are against her. the ordinary man. if of the patient. eliminated and are retained in the circulation . realize the relative infrequency of At the outset we mental disturbances. Uremic coma but it or stupor is so common as not to merit special mention. as malignant disease. however. 4. serves to illustrate in a forcible way the depressive action of retained poisons upon the nervous system. Hale White's case had two attacks of mental disturbance. for example. of delirium and confusion. the symptoms produced are those of delirium. The sleep is usually broken and disturbed by distressing dreams and nightmares. and 16 true of all of the psychoses of visceral . and this is be. must be present. system. THE VISCERAL DISEASES no longer Visceral diseases profoundly affect the organism as a whole.

frequently su- perimposed on a neuropathic make-up. is not attended by much. mild in character. should be drawn In brief. and difficult to follow. may manifest deillusions. g. The be patient talks confusedly.. convulsions and coma may supervene. e. Quite commonly the disturbance any. actively and may much The attack may pass away or may be interrupted by convulsions or may deepen and terminate in coma. The patient or his ideas may be afraid. Patients suffering from Bright's disease lirium. mystic. for instance. cancer of the stomach. if This is the case. painful in type and superficially suggest- ing melancholia may make their appearance in the course of almost any of the visceral diseases. agitated. and both auditory and visual. Now The course of and then the symptoms resemble melancholia. Symptoms tended by of delirium and confusion. may be vague.242 origin. at any time in the course of the attack. Here we have again phenomena of auto-intoxication. Again. in which the patient sodes are attended may be frankly delirious . excitement. . may entertain persecutory notions. however. in malignant affections. at- depression. In other cases the disturbance assumes the form of a confusion with depression. The intensity of the symptoms and the prognosis of the attack stand of course in close relation to the Bright's disease. more especially. is There are headache. the inference that the existence of a delirium or of a confusion which bears no clear relation to an infection or intoxication should always excite the suspicion of visceral or other somatic disease. disturbed. MENTAL DISEASES The relatively infrequent disturbances met with in Bright's disease will serve as an example. the attack may be interrupted by periods of exacerbation. Hallucinations are present as before. of the gastro-intestinal tract and of the to deal with the liver. hallucinations. at times these epi- by great excitement.

profound. and often entertains persecutory marked. occasionally in the rare in- stances of surgical injury of the thyroid gland in which the gland or its connective tissue envelope are torn. and. and. The symptoms The and are those of a more or less active delirium. In exophthalmic goiter. hallucinations. the previously existing lost sight of. Particularly is this true of the thyroid gland. susceptible or when the patient unduly when the dose has been large. delirium only occasionally observed. has vague ideas. The depressed. Here we can distinguish the mental symptoms of hyperthyroidism. and often noisy. hears voices. irritable. when coupled with a The depression is realization of the serious nature of the physical disease from which the patient fusion is suffers. may lead to suicide. He is sees faces. very restless.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 243 The mental disturbance there is in malignant disease patient is is never active. At times the delirium attains a very high degree of intensity. It undue amount may is also occur in thyroid administration. hypo- thyroidism. The mental symptoms and then of hyperthyroidism are met with now in exophthalmic goiter. should be repeated. patient suffers is from hallucinations of sight and hearing actively disturbed. it When the congastric cancer may talk of stomach. of dysthyroidism. the woman with Under all may talk of being pregnant. never a delirium. It may also be attended by a decided is rise of temperature. and finally in opera- tions in which the manipulation of the gland has forced an of secretion into the circulation. . neuropathy should never be DISEASES OF THE DUCTLESS GLANDS Diseases of the ductless glands merit a special consideration. the patient with snakes or other living things in his cancer of the uterus circumstances. suffers from distressing delusions. less clearly.

It is probable that the latter are cases of exophthalmic goiter. which a more or less chronic intoxication follows. that persist for cases in which marked mental symptoms cases are every curiously. Doubtless a predisposirole. dicted. for some reason or other. Such may be in indimay be the of thy- outcome in traumatic cases or cases in which toxic doses roid substance have been taken.244 It is MENTAL DISEASES rather the symptom group and of a relatively mild but chronic intoxication which presents itself. or Ustless. are not pronounced. tion. state. though present. as mental symptoms are pronounced. and is. The depression may be marked and attended be interspersed by by a mild confusion. and this confusion may episodes of excitement or delirium. excitable. as already pointed out. or perhaps a quite depressed and suspicious. however. is might be pre- usually much disturbed and abridged. Sometimes his conis dition suggests a mild manic at other times he little for- getful. indifferent. Very we have here often to deal with cases in which. offers. in which. plays here a The mental symptoms of hypothyroidation may ensue when . though cases is are not wanting in which somnolence noted. Such now and then committed to the asylums. Thus. Sometimes. Again. a frank delirium makes its appearance quite suddenly and withIt out premonitory signs of moment. too. the patient is com- monly nervous. an indefinite period. Thyroid delirium prognosis. a favorable Of course the thyroid intoxication vidual cases so massive as to lead to death. other things equal. the symptoms of the exophthalmic goiter. there are cases of exin ophthalmic goiter in which delirium supervenes. there is a momentary depression of func- tion or exhaustion of the thyroid rather than a hyperthyroidism. a pre-existing neuropathy. happens every now and then that the symptoms moderate or but slightly of the exophthalmic goiter are and imperfectly marked and yet the Sleep. irritable.

especially if apathetic. is There difficulty of comprehension. slowing of the pulse and subnormal temperature. In given cases. There mental phenomena is are present in greater or less degree. Usually they sleep a great deal. it may and then the patient complains of head- Now ache. in addition to the infiltration of the skin. hallucinations it may accompanied. sometimes is being ill-treated. or. is it may The also follow a too radical picture that supervenes of that of the well-known symptom group myxedema. At the pressure is put upon them in the attempt make them hurry. sometimes there a pronounced somnolence. to bathe. that the patient ent. is Now and then it is observed be pres- mildly confused. or to attend to such elementary functions as a movement same to of the bowels.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 245 the gland undergoes destruction or atrophy through some degenerative or diseased process. by distressing delusions. the sausage-shaped fingers. the spade-like hands. there is readiness of fatigue. a true narcolepsy being present. or dizziness. dull. persecuted. the patient sometimes requires hours to dress. sense of pressure. they maj^ become greatly excited and is nervous. faintness. On the other hand. the . the sleep may be both diminished and disturbed. drowsiness or sleepiness comes on in attacks. the swollen features. require an excessively long time to perform the simplest acts. abused. or the patient may suddenly fall asleep for varying periods of time. and. surgical removal of the gland. though less frequently. sive attacks resembling epilepsy and rarely convulIf make their appearance. may be. impaired. Here. time. in addipatients are slow in The their movements. the memory tion. the patient feels that he be. the dryness of the skin. the psychasthenic cases. the patient cannot follow is a prolonged conversation. Mentally the patients are heavy. As in the neurasthenic-neuropathic. a slowing of thought and of mental processes generally.

pituitary e. The importance complete cases of myxedema cannot be Finally. in acromegaly there may be somnolence or there may be apathy and dementia. reveals the truth of Diseases of the ductless glands other than the thyroid are not attended with equally well-marked symptom-groups of mental phenomena. stance. for inthis statement. the . The examination at random of large numbers of miscellaneous cases. special disease of the g. the mental symptoms myxedema are pronounced while the physical signs are not decided or so slightly marked as perhaps to be overlooked. in an asylum. excess of function. In the writer's experience cases of complete. At of times. should occasionally be present such circumstances is not surprising. as a whole. of fully developed. and in which. cases myxedema are relatively In such cases the infiltration of the skin. there are disturbances of the thyroid gland in which the symptoms present do not enable us to classify a given case either as hyperthyroidism or hypothyroidism. on the other hand. as. Possibly in such cases several ductless glands are synchronously involved. under of confusion or delirium. and proper treatment be not mental condition finally terminates in in- stituted. as in adiposis unmistakable psychic symptoms.— 246 affection MENTAL DISEASES remain unrecognized. notwithstanding. or di- minution of function. the dry- ness of the hair. —may be associated with Thus. myxedema frequent. presenting the typical classical of incomplete symptoms are rare. and this is most important. the a dementia. It is also a significant fact that in mental cases.. evidences of thyroid anomafies of one kind or another are relatively frequent. the functions of the gland are affected. At the same time. slight and yet the mental symptoms proof the recognition of early or insufficiently emphasized. the slowing of the pulse may be relatively moderate or even nounced. as in acromegaly. of excitement That a varied symptom-group and depression.

106). probably. brain tumor. the organic diseases. of the hormone of the sex glands and other internal secretions in dementia precox (see p. 332). and paralysis and. unfortunately take us too far referred to the role of the The reader is.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 247 latter sometimes very slight and sometimes very marked. causes acting directly upon the individual himself. thirdly. cerebral syphilis. hysteria. g. thrombosis. Among these are. perhaps also disturbances . sexual and intellectual pre- cocity. 131). the functional disorders. A. many and widely differing factors enter first. chorea. syphilis and possibly other infections in the ancestry. trauma and gross organic disease of the brain. tabes. and also to the possible role of the latter in manic-depressive in- sanity (see p. symptoms may be met with somnolence. embolism. such as intoxications.. demand here a consideration are. in hyper pinealism. it plaj^s a role in paranoia in we should bear mind that the ductless glands form a closely related and interdependent chain. infections. 5. alcoholism. elicits and disturbance in the others. into the etiology of epilepsy. a failure of the cor- responding functions. second. mental impairment or feebleness. however. hemorrhage. secondly. DISEASES OF THE NERVOUS SYSTEM The diseases of the nervous system which especially first. epilepsy. originaria (see p. arteriosclerosis. of one of them sometimes phenomena would A discussion of this interesting subject afield. In disease of the pineal gland there may be. paresis. and. heredity. in hypopinealism. brain abscess. multiple cerebrospinal sclerosis. FUNCTIONAL NERVOUS DISEASES EPILEPSY As is well known. and trauma. in pituitary deficiency. Similar e. Perhaps Finally. In adrenal disease there may be depression. agitans. neuropathy.

be accompanied by mental symptoms. sometimes and sometimes and marked degree. a high and narrow palate. that there should be a multiplicity of causes. perhaps just what we should have been led to expect. save the ness accompanying the attack. anomalies of dentition. It is just in this group of cases that we factors in the ancestry such as epilepsy or other neuropathy. It is in this group that we have to deal with individuals whose development has taken place in an aberrant and damaged germ plasm and in is whom the epilepsy It is to this expressive of an endogenous autotoxic disease. of the cortex would appear that the motor area responds by convulsive attacks to both chemical and physical irritants. is noted. and alcoholism. but the descriptions which follow relate only to the epilepsy of the morphologic or essential group. group that the term morphologic or essential epilepsy seems clearly applicable. at times special psy- . the evidences of morphological arrest deviation. anomalies of the ears. of the digits. Sometimes the arrest characterized not so much by physical signs as by a mental development distinctly subfind significant normal. and. The epilepsies of other origin may. Among these are anomalies in the size and shape of the skull. loss of conscious- Frequently no psychic disturbance. syphilis. in the habit of including we are many symptom groups which differ widely as to their origin and pathology. is While a classification of the epilepsies a matter of extreme difficulty. surprising It Perhaps this is not when we reflect on the physiology of the brain.248 MENTAL DISEASES Under the caption of epilepsy of the internal secretions. more or less related to the special cause of origin. The psychic manifestations of epilepsy vary very greatly. all in given instances. any one or number is of which may bring about an epileptic symptom group. we can in in safely separate out from the great mass in slight of cases a group which there are present. is and of the general develop- ment.

the patient learns with in a comparatively limited horizon. a more or of marked impairment tion progresses. this becomes evident.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS chic 249 symptoms are present and precede the attack. . itself memory becomes be slight at evident as the affec- It may first and may manifest Later it only by an occasional forgetfulness. epileptics who. Further. less As mental deficiency due to other causes. little indeed. we soon reahze that his mental processes are this. the greater number. and he may be quarrelsome and easily angered. which the patient later gives of himself varies from time to time and becomes. Finally. and by far who present both emotional irritability and mental impairment. In keeping with he is commonly dull and apathetic and at the tional same time unduly readily disturbed. sudden outbreaks of anger from or no cause are is not infrequently observed. as in other affections in which a mild dementia difficulty is becoming established. It is noted. however. furthermore. that mental deterioration ensues in long- standing cases. both which is in his replies to questions and in the account in elicited of his symptoms. his mental activity distinctly diminished. but distinctly slow. and at others still replace the attack. are entirely normal. in the intervals between the seizures. difficulty of Usually the epileptic has no is comprehension and his faculty of orientation unimpaired. but more frequently are very evident. until finally the history may be- come more marked. at others follow the attack. are apt to pursue the beaten path. There are. and lives His thoughts lose their spontaneity. and. of course. His emo- equihbrium is his inliibition is di- minished. a careful study of the epileptic in the interparoxysmal periods frequently reveals special phenomena which distinguish him from the normal individual. and are able to follow their vocations fairly well. There are others. irritable. These symptoms may be slight.

he depressed. in which the mental processes are distinctly modified or retarded. and yet the suspicion that the attacks from which they suffered were really hysteric It is is not without justification. is mentia. that a certain degree of mental impairestablished. of as exist in persons of unusual or thus. significant. sometimes prolonged. or in which the . exist for is There are some yet in in whom the attacks many The years and patients whom little if any deterioration noted. however. whom seiz- ures have recurred with great frequency and great severity in whom the deterioration finally is relatively rapid and progressive. and yet the patient that he is may answer getting better. At times he seems to be afraid and suspicious. uncommon. further shown by condition. Profound de- and who become markedly demented. properly be tained as to the accuracy of statements to the effect that epilepsy may not only be unattended by deterioration but may even phenomenal mental endowment. the patient's inability to realize the change in his own Both the seizures and the mental impairment may be growing distinctly worse. also. it may be. both Caesar and Napoleon are commonly spoken epileptics. may for a long time pursue quiet and enter- well-ordered lives. differs greatly in different cases. More interesting and more important than epileptic dementia are the episodic mental states. as already indicated. These consist of periods some- times very brief. clearly unreliable. There are others —those. Doubt may. such as is met with in other terminal states. however.— 250 MENTAL DISEASES Mental obtusion is in part at least. The mental state of epileptics. and. and at others may evolve persecutory ideas. ment becomes gradually and very slowly patients then remain and the in this impaired condition still without further in change. usually changing and transitory. is rarely a distinctly expansive attitude noted. occasionally.

in which case Again. heavi- ness are increased. They may by immediately precede a convulsive seizure. or performs various comes. talk of something terrible about to happen. He may become Sometimes a kind sullen. about him. he becomes suddenly passes through various automatic movements. runs. of psychic erethism present. and manifests fright. not only emotionally but at times also intellectually. Sooner or later the convulsive seizure follows. or it They may precede the seizure may be for a day or more.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS patient is 251 mildly or actively confused or delirious. At other times. goes. several hours. sometimes as a larvated epilepsy. the mental symptoms may entire attack and thus replace altogether the convulsive is Such a case commonly spoken of as a psychic epilepsy. follow a seizure. and sometimes bizarre acts. itself very fre- Not infrequently. the patient may suddenly become of ruin excited. patient become accentuated. Some- times the excitement is very intense. He may in such case be restless. in which case they sequelae. first. dulness. that the peculiarities ordinarily noted in the irritability. though rarely. in which case they constitute a psychic aura. and destruction. The psychic aura when present manifests quently as a sudden fear or instance. and even. talkative. may may be regarded as psychic constitute the seizure. the outward signs of an intense In other cases. screams. for have a convulsion suddenly all clings to its mother. they they are spoken of as psychic prodromata. If the mental symptoms manifest themselves His as prodromata we observe. expansive. more apathetic. is more quarrelsome. unable to comprehend what said to him or what is going on agitated. and the patient may suddenly become destructive and may make violent attacks . or he is may suddenly become stupid. a child about to fright. the patient becomes very excitable. Finally.

all and mental manifestations cease. hallucinations Occasionally the seizure is less pronounced. mental less may be present in more or marked degree. Sud- denly there hearing is an outbreak. other things equal. The patient screams. The various forms which the psychic aura assumes the convulsion appears are relatively short in duration. frequent. As a the duration of the attack is several hours. the symptoms assmne the form Delirium the attack is. and has terrifying delusions. apathy. dulness. As a is rule. When it occurs. confusion frequent after the convulsion However. especially in cases in which the seizures are very severe or occur in groups. on the whole. He struggles. lucinations terrifying halis and delusions are present such cases very- probable. is the case.252 MENTAL DISEASES That in on the persons and objects about him. either of a con- fusion or a delirium. several days. the most preceded by depression. the shorter the dura- . He is entirely oblivious of his surroundings during the seizure. The and delusions are less active and consciousness may not be so completely obscured. is Often there a history of frightening dreams. Compared with purely psychic epilepsy must be regarded as very infrequent. The patient complains of strange sensations or of a dazed feeling. blood. frenzied efforts. Sometimes confusion persists for several hours. and ma}^ even kill while in this condition. and subsequently has no recollection of what has occurred. makes wild attacks. When or the mental disturbance constitutes the entire attack. flames. larvated epilepsy. spoken of as psychic ordinary epilepsy. Vivid hallucinations of sight and make their appearance. cries out. hears terrible sounds and voices. less Psychic manifestations are has occurred than before. or perhaps as much as two weeks or more. as has already been stated. and evidently sees terrifying objects. rule. The more active the excitement.

Finally. in rare instances. several weeks. is The stupor that of an may be complete. a deep confusion. he will The somnambu- . in which the patient may manifest purposeless and automatic movements and gestures. The confusion may in given instances its deepen into stupor or the latter may make appearance suddenly. is lost. Sometimes the subsidence to lucidity is is of the symptoms and the return more frequently the return rapid or even sudden. Occasionally or. more frequently the condition incomplete stupor. consciousness and when the attack is over the patient has no recollection of what has occurred. it may is be very deep on the other hand. assumes the form of a somnambulism. terminal to a delirium. the violence of the outburst to a less active phase. the patient This confusion attacks may be active or may suffer from confusion. 253 give Again. his bed.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS tion. As a last rule such an attack lasts one or two days. so light that the patient merely somewhat dazed. or even longer. Again the may be evanescent in their duration or excessively prolonged. or the attack. As in the case of epileptic delirium. two weeks. may leave walk about. is may gradually way and this is usually the case when the attack prolonged. the con- fusion occurred in brief episodes of several minutes. it may be slight. Instead of delirium. or may betray in other ways evidences of a confused and hallu- cinatory state. gradual. substituted by a psychic outburst In such instance the patient may have an The patient of terror or of a short delirium. is Occasionally a nocturnal epilepsy attack. In one of the cases studied by the writer. though it may a week. and perform various complex acts of which subsequently have no recollection. apparently replacing less frequently recurring convulsive seizures. In other cases the confusion may be more pronounced and last it is several hours.

appearing most frequently in men. There are instances in which the patient passes into a dazed condition. hysteria must be clearly differentiated it from the fatigue neurosis. and conducts himself and finally a way as not to attract special attention. may without the presence of a single fatigue symptom. However. makes purchases. Again. in which the patient has an all-convincing sense of illness. however. the cause of which he usually refers either to his digestive tract oj to his sexual organs. however. It is probable that include among the mental phenomena of epilepsy we should some forms of double consciousness. when none of the other psychic or physical manifestations or stigmata are present. excessively rare. it must be sharply is differentiated from hypo- chondria. of purposive deception must always. travels. and the possibility of hysteria.) Space will not permit of a consideration in this section of either gastro-intestinal or sexual hypochondria^ . with which exist has nothing in common. Especially this the case when no previous history of epilepsy. much less complete and prolonged than that met with in hysteria. (See Part II. in which he performs a series of complex acts. In the first place. without any knowledge of arrived there or of any intervening events.254 MENTAL DISEASES is lism of epilepsy. is in such instances. how he Cases of prolonged duration are. just constantly exists without the presence of a single organic as it lesion. Chapter III. It neurasthenia. be borne in mind. so much misapprehension and confusion exist in regard to the subject as to necessitate a presentation of the facts. of fraud. comes to himself in a distant place. HYSTERIA It may be properly questioned whether hysteria has really a place in a text-book on mental disease. In the latter there a characteristic symptom-group. buys railroad in such tickets.

suffice it to say that there is never present a single stigma of hysteria. Happily. from the Greek word for uterus. as a matter of fact. mental or physical. and likewise only in relatively recent times that the idea that hysteria is dependent upon disease of the uterus or ovaries has been it is abandoned. not be necessary to point out that the mere fact of a nervous symp- tom being obscure terming it or not understood does not justify our hysteric. the impulses of psychasthenia. considered in Chapter VI. and is based upon the idea of a causal relation between the uterus and the symptoms. the indecisions. unrequited of genital and lastly. ideas as to the sexual origin of hysteria have persisted. Hysteria. repressed sexual desire. though the Freudian school has hopelessly confounded the two conditions. satisfied Unlove. passion. the phobias. Hysteria is an independent nervous affection. haripa (hystera). With equal force must hysteria be differentiated from the neurasthenic-neuropathic symptom-groups.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 255 but. The early Greeks believed that its during a hysteric attack the uterus becomes detached from moorings and goes wandering about the body seeking sexual satisfaction. is What The then hysteria? Space and the objects of the present volume forbid more than an latter is derived allusion to the origin of the name. It is interesting to note that in our own day. however. out that hysteria is no longer necessary to point it uninfluenced by pelvic surgery and that occurs in the male as well as in the female. repressed memories sexual it is peccadillos in childhood have all had their advocates. while the crude theory of the wandering uterus has been abandoned. irritation. the psychasthenias. What is its . bears no relation to the special form of neuropathy presented It should nor to the accompanying neurasthenia. bears no relation to the fixed irresistible symptoms.

thesia. sensory. e. The symptoms may be conveniently divided and psychic. volved. his pupil Gilles de la Tourette. as a glove-like or stocking-like it anesthesia. Evidently such a loss is it not in keeping with any known fact of anatomy. If cover in a patient an anesthesia. Sometimes . shift in distribution. A summary of them only can be attempted here. we outline the area in- we j&nd that it bears no relation either to the distribu- tion of the nerves or to the sensory representation in the spinal segments. may involve the entire half of the body. i. is that such a symptom is mental. there is More frequently than anes- merely a diminution of sensation.256 nature? If MENTAL DISEASES we examine its symptoms. or vary in intensity. and it is due to Charcot. somatic. sent itself. it limbs. go. Simple hyperesthesia may in its distriit is bution resemble anesthesia or hypesthesia. and their followers its that we to-day possess an adequate picture of symptomainto tology. we dis- by the fact that they are of psychic origin. may come and The only i. we are at once impressed Thus. and constitute a geometric anesthesia.. there may be present a hyperesthesia or a hyperalgesia. or head. or a foot and leg a stocking. e. Instead of a loss or partial lessening of sensation the latter may be increased. psychic in The French have elaborately studied hysteria. it when known as a segmental anesthesia. and hyperesthesia or hyperalgesia. a hypesthesia involving like areas.. The anesthesia may pre- as above described. may be limited to an irregular patch upon the trunk. possible inference origin. forming a hemianesthesia. Finally. motor. Quite commonly the loss of sensation embraces like an area covering a hand and arm like a glove. The sensory symptoms consist of anesthesia. hypesthesia. it is may involve merely a segment of a hmb.

when we examine the i. The somatic 17 or visceral symptoms of hysteria consist of such . such as an eye-muscle or of the extensors in wrist-drop. the entire in the limb of has been sensory clearly elided from consciousness. e. As case the is phenomena. so-called spinal tenderness. for instance. inframammary tenderness. but these we not pause to consider. manifests itself in the form of isolated and oval-shaped patches of sensitiveness. as a small oval area im- mediately above the groin. of contraction. just below the so-called mammary gland. of incoordination. there is never a palsy of one muscle or of a group of muscles. of tremor. when the it symptom pronounced. in spots Painful areas are also met with no larger than the tip of the finger on the scalp. Further. also cavities on the mucous membrane of the buccal and nasal of the and rectum and vagina. the palsies bear no relation to the facts of anatomy.. movements. as a small area to one or other side of the spine below the inferior angle of the scapula. These patches may be found upon fre- any portion of the trunk or limbs. though they are most quently met with in certain situations. thus. is Most frequently.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 257 widely spread over a limb or over one side of the body or portion of the body. so-called inguinal or ovarian tender- ness. whole. as small spots or areas over the spine. the mental evident. origin is of the symptom in The same truth discernible the motor phewill nomena other than the palsies. however. over the back in traumatic cases. of hysteria manifest themselves in The motor symptoms and of convulsive the form of paralysis. more especially as a small oval area over the ribs. of there has been paralysis both motion and sensation. but the paralysis involves the limb as a limb. As in the case of the sensory symptoms. we usually find that sensation also has been lost.

of these symptoms. cough. hundred consecutive cases viously examined of hysteria. when analyzed. vomiting. polyuria. The psychic phenomena lying of hysteria are not only the underin causal relation to all of the all phenomena that stand others. he failed. retention of urine. has the brush or esthesiometer in his right hand. aphonia. and naturally tests the left side of the patient's is body first. yawning. The objective symptoms were. but they are the phenomena which most of concern us here. or dilatation.258 MENTAL DISEASES as loss of appetite. nor there any evidence of some such purely physiologic cause as pregnancy. with due preIt is cautions. to discover hemianesthesia. He claims. interesting also to add that anesthesia of the special senses. la adequately described by Charcot and by Gilles de Tourette. Each and every one origin. but remained for Babinski to point out that the symptoms have suggestion. anuria. phantom tumor. rapid breathing. vasomotor phenomena changes. maligis disease. for instance. contraction of the . in suggestion that their origin in may arise from causes within as Babinski also main- well as from causes without the patient. as already stated. thus sugIn one gesting the anesthesia which he trying to discover. no evidence nant disease. tains that the sensory losses of hysteria are always the of inadvertently outcome is made suggestions at the time the patient examined by the physician. rapid pulse. Again the symp- toms can be relieved by suggestion or perhaps conquered by massive feeding. which had not been pre- by other physicians. ulcer. that the reason hysteric hemianesthesia predominates on the leftside of the body is because the physician being usually right- handed. These investigators also laid great stress upon the increased it susceptibility to suggestion in hysteria. reveals a psychic is Thus the vomiting there is never attended by the signs of organic of gastric catarrh.

Just as the so are they symptoms of hysteria are produced by suggestion. curable by persuasion. "I cure"). loss of taste side. here. objects. as signs is we have seen. restless. avoids the members perhaps of her household. several hours. imperfect. and because {r. During this period the patient frequently becomes depressed. extending over a it number of minutes. perhaps a little exuberant or even boisterous. its real Equally is this true of mental symptoms when is they are present. deafness. the palsies and the sensory losses im- press us with their unreality is and unessential character. of something vol- untarily and artificially produced. as in the case of the physiof the symptoms have the appearance something that is not genuine. states of excitement suggesting dehrium or confusion are cal signs. as possessing a factitious character. and there usually difficulty in making the differentiation. of something assumed. over a day or two. Hysteria." and Idw/uu. met with. or.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 259 visual field. she acts as though she had frightening visions. Less frequently still. in short. there something about the case which even to the layman suggests nature. Let us turn our attention to the hysteric paroxysm and the attendant mental phenomena. and is angry or weeps upon slight provocation. The simulation and of mental disease grossly At most. irritable. is uncommunicative. Thus. and smell may also be found on the anesthetic doubtless due to a spreading of the suggestion of sensory loss. is Less fre- quently the patient excited. but this simulation is little imperfect. may be. or she may laugh and weep by turns. of this fact Babinski has devised the name pithiatism "I persuade. saw strange faces and Very commonly she complains . may be attended by physical which may simulate organic disease.eicj. commonly removed by suggestion. Usually the attack is preceded by a prodromal period.

submits to the ministrations of her friends. obscene. depressed. however. the attack may pass into a phase in which the patient seems to hear voices. says that she can- not breathe. clutches at her throat.260 MENTAL DISEASES of choking sensations. and conducts herself normally or perhaps goes to sleep. which are much greater in epilepsy acter. is and in which she utters disconnected phrases. may be Soon. Contrasted with a . a fact that patient. nor there ever any biting of the tongue as in epilepsy. is Sooner attended present at or later a convulsion comes on. is The sphincter control is never lost. has headache or other distressing feeUngs. exalted. Sometimes the patient tears her her person. It is characteristic of the hysteric attack that the patient does not lose consciousness." is times. an "arc de cercle. shrieks and weeps. indeed. times the fact that the patient is conscious during the attack self-evident. Little by little she becomes quiet. The patient never hurts herself and betrays by her actions or by her subsequent statements a knowledge of her environment. to see visions. in extent than those seen and of themselves usually suggest a voluntary char- Hysteric attacks are of variable duration. and in the latter the patient contort the body into various bizarre positions. but is rarely admitted by the some- commonly capable is of convincing proof. others more prolonged. assumes dramatic and passionate attitudes. dishevels purpose. the patient appears to pass into a condition resembling somnambulism. some are brief. Instead of subsiding. an present. erotic. opisthotonos. or gestures and may may make movements clearly expressive of volition and clothing. picture suggesting a frank dehrium is A rarely observed. The convulsion by a tonic of spasm. At other times. during which the patient all may rigidity of the muscles of the limbs and trunk. the tonic spasm followed by clonic movements.

may follow a convulsive attack or It is usually of short duration. may be. sometimes a few minutes. rarely it recurs with interruptions of lucid intervals for longer periods. In some cases a serious and persistent mental disorder supervenes in a chronic form. dramatically calls him by a strange knows exactly name. or a narcolepsy. neither the incoher- ence nor the delusions recall those of delirium proper. The illusions of persons and objects are often exhibited in such a rise to way as to give the same conviction. in a hysteric sleep or coma. give the bystander the impression of being assumed. at all Long times with a rich emotional content. A hysteric attack may it eventuate in a stupor.. The visions which the patient sees. extending a fraction of an hour to several hours. it themselves the outcome of visceral sensations. It is among the rarer conditions met with. spoken of sometimes by German writers as a "Daemmerzustand. who the designated person Finally. being told that a certain person her father.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 261 delirium due to an infection or an intoxication. or. and yet a moment later betrays that she is. sometimes a few hours. A mild confusion. Such a stupor or sleep recur at intervals and on independently. a few minutes or hours." a twilight state. not genuine. a crass differ- ence becomes apparent. is The patient. The duration Sometimes of the attack is usually quite short. sentences and long phrases. the patient acquires the . rarely a day or more. upon suggestions received from without. it merges into a confusion. and which she dramatically addresses. e. sometimes to a day or more. Based either upon auto-suggestions. i. may is may come may simulate from The sleep of variable duration. may come on independ- ently. replace the unrelated fragments uttered in the genuine affection.

of the ovaries. this is a pathologic susceptibility to suggestion. . is the normal individual suggestion. is proof that in the one there is pre-existing an abnormal condition which clearly absent in the other. Such a patient happy unless she list is under a physician's or surgeon's care. She develops a memory that its painful in minuteness.262 belief that she is ill. general emotional instability. and the symptoms of which may be developed by any incidental factor which may act as a suggestion. The neuropathic repels. sewing fast one or both kidneys. one that depends upon the innate organization of the individual. are therefore likewise features of the hysteric neuropathy. just as the reaction of the hysteric individual to suggestion is excessive excessive and pathologic. exaggerated emotional expression. The inference obvious hysteria . and retails with endless elaboration experiences is with not various physicians and various cures. is the expression of a neuropathy whose cardi- nal feature is feebleness or absence of resistance to suggestion. Such patients are among the most difficult with which the fact that so crass a physician has to deal. Hysteria an inborn. and she constantly is demands medical attention. of the uterus. Further. any other. indeed. Sometimes the is of operations through in which she has passed appalling. and may include one and the same case removal of the appendix. the individual accepts. She becomes self-absorbed. her craving for sympathy becomes more pronounced. an inherent neuropathy. so is his reaction to emotional stimuli and pathologic. The symptom as hemianesthesia can be developed in one individual by suggestion. excision of the coccyx. and that suggestion in another individual fails altogether to ehcit this is symptom and is or. Exaggerated emotional reaction. Her symptoms become greatly exaggerated. MENTAL DISEASES She becomes introspective. and recites and repeats with evident satisfaction the account of her various symptoms and her affections.

in Finally. the physical reaction. Charot and his pupils all regarded hysteria as always inherited. One group of ideas. requiring considerable time. In this state the patient may perform automatically various acts. to use Charcot's expression.. Such symptoms. there is a separation of the personality into two parts which have no relation with each other. have merely the value of agents provocateurs. and bearing no relation to the occasion or to the environment. other causes. the hysteric individual reacts inordi- nately to fright. limb. may As has just been stated. at . e. anger. an entire his consciousness. hysteria is it a neuroppresents athy of degeneracy and keeping with this fact a large element of heredity. as in the somnam- buhsm of hypnosis.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 263 In keeping with this fact. is. the other hand. the patient subsequently claiming to have no recollection of what has occurred. is excessive. often com- plex in their nature. mortification.) The cleavage of the personality may be still more complete. fancied slights or wrongs. disappointment. i. It follows as a physiological corollary that the outward expression. Indeed. to all intents oblivious of his surroundings. one half of the body. a hysteric seizure may eventu- ate in an attack of of somnambuhsm on . annoyance. Such attacks usually terminate quite suddenly. (See Part III. so that the patient for long periods of time acts exclusively under the influence of one group of ideas and associations. an attack somnambulism may come on spontaneously. The personality of the hysteric is a vulnerable one. joy. shame and kindred incidents. and during and pur- the performance of which the patient poses. can only be accounted for on the basis of a psychic dissociation. Chapter I. occupies the field of consciousness to the all complete exclusion of others. and. may be elided from at another time a veritable cleavage of the personality occur. when genuine.

and the story still which related by the patient reveals a more remarkable instance of a dissociated or personality. Regarding some of the reported however. a legitimate doubt of their genuineness may be entertained. every hospital physician knows. case studied by Morton herself. with the outdoor service of which he was connected.264 MENTAL DISEASES and conducts himself as though he While in others. where. who disappeared one morning from home in Providence and reappeared two months later in Norsmall ristown. Prince. he had conducted a The is stationery store. paid for food and lodging. and it may be in his properly inferred that he had purchased it. He had lost his evidently purchased boarded a train. gross deceptions in order to secure the That they practice sympathy and attention That they which they crave. and enjoy occupying the center of the stage. he was wearing a cap. of another group. . He did not appear at the clinic. The patient was his an itinerant preacher. nor was anything heard of him for two days. and nothing demeanor had attracted attention. He came of to himself suddenly in a fright and asked to know where he was. He had no a ticket. or how he had gotten to the place at which he found himself. disintegrated cases. one state he has no knowledge or recollection of his actions. He suddenly came to himself on a country road. under a new name. the latter was new. many miles from his home. he had also apparently straw hat. when he came to himself. Evidently he had committed no act which had been unusual. because the by William James. were possessed of two personaUties. idea of where he was. reported interesting. and experiences in the other. thoughts. gone to a hotel. left his office to One morning a young physician go to a hospital. for. is The case of Ansell Bourne. even more change to the abnormal personality was of longer duration and more complete. Hysteric people often like to be interesting.

ill. e. an active delirium supervenes. appearance. and the child may be quite stupid and may reply to questions with difficulty and in monosyllables. too. girls In the older patients.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 265 will simulate anuria. chorea be very severe and prolonged. it In conclusion. these symptoms the be- may come more pronounced. and personality. that they will undergo severe procedures. are. human not motive is sometimes very obscure. true alike of delirium especially double and confusion. while somnambulism. g. Further. and in no case difficult this more of than in hysteria.. with hallucinations. severe. That they may lie concerning so interesting a phenomenon as is double personality extremely probable. HowIf often slow and heavy. a mild or a decided confusion. in chorea occurring during or follow- ing pregnancy. are decidedly rare. rise of temperature. CHOREA Pronounced mental phenomena are rare ever. Rarely. not always possible is to separate truth from falsehood. are usually very the choreic movements pronounced. spoken of as chorea insaniens. or what not. infrequent. may be said that hysteric mental disorders This is on the whole. in is order to achieve this end a matter of common knowledge. The remarkable experience Ernest Hart with some of Charcot's patients may be recalled by some of my older readers. and sometimes hebetude and apathy are expressed by the features. and the reason may always be apparent why a man is should conduct himself in a manner suggesting that there or possibly for a motive for concealing himself making an entirely new start in it is life under entirely new conditions. may make its Such cases. especially in about the age of puberty. Unfortunately. face painful operations. the choreic child is in chorea. and the exhaustion a not infrequent outcome. Death is .

Hallucina- B. despite is the distressing affection. even the nerves. depression is in paralysis agitans. fairly well preserved. The patient becomes slightly depressed. the affection is a prominent part of the attended by profound organic changes. symptoms. still less Less frequently he becomes suicidal and cutory. in keeping with the . symptoms appear and At and first they are exceed- ingly ill-defined. while the mental symptoms form clinical picture. mental late. and and at times confused and hallucinatory. However. in given instances. but also the spinal cord and. though noted. remarkable how well the majority of the patients bear their affliction. tions of taste have been described. it is now and then met with. which becomes more marked with Notwithstanding. Very rarely are there hallucinations of the other senses. darting across the walls and ceiling and which frightened her very much. ORGANIC NERVOUS DISEASES PARESIS Paresis is an affection which is not usually classified among nervous diseases. irritable. many years' duration in which the mental condition. One of my patients black objects. is not uncommon. Sometimes. vague.266 MENTAL DISEASES Cases of Huntingdon's chorea now and then develop mental forgetful. general. These changes involve not only the brain. the early symptoms are purely peripheral. In the great majority of cases. while cerebral and mental symptoms make their appearance relatively ever. often perse- A mild dementia. there are cases of time. howearly. which she took to be mice. Now and then a mild confusion is Somesaw times hallucinations are present. PARALYSIS AGITANS Mental symptoms are very infrequent However. again.

and. in the cerebrospinal fluid with 0. Finally.c.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 267 fact of a diffuse involvement of the brain. Further. Levaditi and Bankowski. and 90 per cent. by the time the clinical examination made. are already so far advanced that their statements as to their past history are no longer trustworthy. The latter. on the whole. Es- pecially genitally may this be the case when the fact lesion occurs extraparetics. times confirmed. to be preferred. Hoche). being a mononym. and innocently. which in their It is is attended bj^ certain- —and. however. The name is. and paresis. the cases in the blood. the epochin the brains of making discovery paretics of the Treponema pallidum last link in by Noguchi forms the the chain of evidence. and fully 100 per cent. or indeed of any venereal infection whatever. We must remember. paresis is now in common use. and Foerster and Tomasczewski. syphilis. exists in It is true that a percentage of cases which no history of syphilis can be obtained. the Wassermann of reaction positive in almost 100 per cent. The that without exception. paresis consists of a slowly In its essential oncoming and progressive de- mentia. progressive general paralysis. are wonderfully tolerant of iodids and mercurials is a fact of great is clinical value. paretic dementia. among which may be mentioned general paralysis of the insane. namely. —An increasing knowledge of paresis has enabled us to fasten with certainty upon one and the sole factor as the cause. that is many cases. general paresis. it may be added. paralytic dementia. known by a number synonyms. Marie. Etiology.2 c. Further. features. Noguchi's discovery has since been many Among the earlier observers were Marinesco. that the initial lesion may be relatively slight and insignificant and is may thus escape detection or recognition well known. when relatively large quantities of the latter are used (Nonne. ensemble — characteristic physical of signs. .

lessens antitoxin-forming power. that other contributing and role. . develops paresis. That is this balance is disturbed in the tabetic likely. however. therefore. and this whom the infection has been acquired many years before and in whom the individual has been the host of the germ for ten. when the vigor of his metaboUc processes begins to give way. strain plays in the development A far more potent reason. evident.268 indeed. in order that the integrity of nervous structures should be maintained. and thus favors both an increasing invasion and an increasing propagation of the parasite. and a It is rather small percentage at that. exhaustion of Some years ago Edruger pointed out that. or. only a percentage. nervous overorigin whatever. MENTAL DISEASES demonstrated the presence obtained of living spirochetes in material from paretics by brain puncture. when his biological resistance begins to flag. it may be. typical syphilitic lesions being produced. It is for a similar reason that paresis commonly fifties. fifteen. is to be found in the fact that exhaustion its diminishes the defensive reactions of the organism. there must be a proper balance between the consumption functional exercise) of nerve substance (as a result of its and the restitution or upbuilding of that nerve substance. too in patients in even forty years. The statement can now be definitely made that without a previous syphiUs there can be no paresis. A moment's reflection calls to mind that of those who are the victims of syphilitic infection. strain. appears only as the patient approaches the forties and that is. and the paretic extremely and probably this in a measure explains t'he role which nervous overwork and overof paresis. predisposing factors must play a Among any these are overwork. also. doubtless. twenty-five. twenty. while Noguchi successfully inoculated rabbits with the substance of paretic brains.

acquires some quality of paresis. However. a powerful contributing factor. or in which a number of all men having acquired syphilis from the same woman. and Europeans suffer. Italy. by the fact that in Java Algiers. Per- Mohammedan by a countries. America. to such factors as exhaustion The from same value must be assigned previous illness and from sexual excess. In America. it Regarding trauma. these facts is true of foreigners significance of The somewhat doubtful. races It is conceivable that the more susceptible have acquired a lessened resistance of living as a result of their ization. France. It is conceivable that infection of the nervous system having once been established. certain facts suggest that. however. It is difficult which especially favors the development otherwise to account for instances in which husband and wife both suffer from paresis. again. at times at the virus of syphilis undergoes some change. it may be definitely stated that the relation between is and paresis that of sequence only. and India. trauma may is prove very injurious. paresis quite frequent among negroes.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 269 Alcoholism. common in England. is dis- proportionately from paresis. cause. because is it likewise lessens the defensive forces. or some other as yet unascertainable least. greatly Trauma. Iceland. Germany. method —an overstrenuous civil- an abuse of alcohol. cannot cause an interesting geographic paresis. as compared with the natives. thus. That certain races possess a greater susceptibility is proven. the rare. haps this is to be explained relatively greater strain is and intensive living. Ireland. and the same as compared with the natives in Bosnia. as pointed out by Kraepelin. in Scandinavia. in many cases. and it is the Slavic countries. paresis. also. as the resistance of the paretic diminished. infected by the use of the same mouth- . it Paresis has is distribution. or relatively so. subsequently develop a number of the instance reported by Brosius of all glass-blowers.

it is. sis —The symptoms and course of pareand slowly-increasing finally are those of a gradually on-coming dementia. cases its due usually to inherited though it may have origin in syphilis acquired in infancy. and with doubtful exceptions —terminates in death. Its It is rare before twenty-five lies and rare after sixty. is a juvenile form. paretic. . Paresis occurs very infreclass. Compared with the adult form of course. is Perhaps four to one of would fair Paresis an affection which makes its appearance during is. greatest frequency It also occurs in between thirty-five and forty-five. sixteen. approximation. that male patients largely predominate. is quently among women of the upper class. relatively of the frequent among men of the same is Among women all classes lower classes the munber much greater. illustrates same Certainly such occur- rences as these can hardly be accounted for on the basis of coincidence. it must be added that than in rural paresis relatively more common in cities districts. Very exceptionally juvenile later. or eighteen years. MENTAL DISEASES and of whom more the than haK became either tabetic or fact. though here also men be a still predominate.— 270 piece. that between thirty and fifty years of age. The ages of the patients are usually in the neighborhood of fourteen. also. Among is other important facts. S3miptoms and Course. there is a progressive mental and physical deteri- which becomes more and more profound. is The proportion and of the sexes somewhat variable. oration. and Hoche speaks of cases beginning as early as the fourth or fifth year of life. and in such sjq^hilis. the most strenuous period of adult hfe. rare. paresis occurs earlier and sometimes Cases of twelve and even eleven years of age have been reported.

pains of neurasthenia. and. As a matter it of is one stage merges insensibly into the other. recognition of the disease in its earliest beginnings is is difficult.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 271 It is quite common to divide the course of the affection into is a number of stages. both convenient and useful to confirst. but insistently dwells upon . of the fully developed. third. as is well known. Inaccuracies and changes in the quality of his work are among the first is symptoms observed observed. and Such information as we obtain from is the paretic in regard to his bodily sensations usually elicited by questioning only. must not be inferred that these stages are clearly differenis tiated from each other. and there are never present the fatigue aches. symptoms as related to three stages: those of the initial period. but by those about him. but a brief examination soon shows that this suggestion is very remote. those of the terminal period. brought to a physician by relatives or is As a the statement made that he has not been well for several months. true more especially of the beginning. that he rule. not the case. not only volunteers this information. sider the It is. and of the final therefore. The very ill. The neurasthenic. and that he no longer attends business properly. the symptoms vary both This is and in intensity at various times. second. acter However. those of the fully developed period. it is characteristic that this deterio- ration by the patient. The friends often tell us that his appearance and manner have changed. periods. it is is The patient himself does not realize that he and only after symptoms have been present for a time friends. is The patient's condition may suggest that he suffering from neurasthenia. or no longer does his to his work as well as formerly. not . Rarely does the patient actively complain. while there it much justification for this. and usually quite impossible to say definitely when one ends and in char- another begins. for this fact.

however. it assimies a tabetic character. the differentiation from neurasthenia becomes absolutely certain. if Even the migraine-like they occur at all. slight haze between himself and the exforgetful. attacks. may be limited to but a few seizures during the entire initial period. Usually he pale. On the should be added that distressing and painful sensations are infrequent in paresis. ing migraine Pain in the head of great severity and simulatat times the pain is may also occur. after physical signs have made their appearance. He may act as though there were a ternal world. Such an attack whole. loses the connection of what is being said. His attitude. if may be present. suggest an ophthalmic migraine. pressure. little Gradually the mental symptoms become a more pro- . but more often. at other times of dizziness. may it referred to the supraorbital and adjacent regions and especially to the eyeball. lightning-like and shooting. Later. on the other may be somewhat somnolent during the day. backache. cannot fix He does not He is absent- his attention as before. cannot follow a prolonged train of thought. or of a dazed or stunned feeling.272 MENTAL DISEASES and other fatigue pains. or muscse volitantes. is there be pain. or con- striction about the head. at other times he pre- sents a heightened color. his face lacks former vigor of expression. Sometimes he complains of ringing in the ears. Vague aches. his headache. Soon he becomes time he During this may sleep badly. misses the point of a conversation. he may be broken. fall asleep with difficulty and the sleep hand. He and may complain —though rarely —of fulness. apprehend or comprehend as readily as formerly. its Quite commonly. suggesting rheumatism. too. all may suggest a general loss of tone. minded. The a little paretic patient quite commonly is looks tired and perhaps somnolent. sparks before the eyes. He may or. his walk. his movements.

become dull. expose his person. esthetic sense. His feelings. or may manifest eroticism in other ways. too. latter are filled in with purely fictitious material. He forgets recent events. omits some does not adjust his clothing properly. The patient overlooks important matters. attempt liberties with members of the opposite sex. and the theft merely an evidence of his absentmindedness and increasing dementia. and irritable. confuses persons. Disorders of He may memory become more pronounced. is article of clothing. Hand patient hand with the general mental gross deterioration. 273 There is an increasing difficulty of attention. or even to whom he is speaking. answer questions fairly but may forget where he the circumstances in which he finds himself. cannot give a clear consecutive history of his case. as in the instance of a forgery. He may is. or His conduct. misplaces objects and papers. forgets engagements. repeats himself in talking. shows that he proprieties. He can no longer observe closely and he tires very readily. clearly the result of . become coarse and obscene in speech. is He may commit theft. the act 18 is At times again. frequently the object stolen can be of no use to the patient. apathetic. perhaps loses himself in accustomed places. the may become and intemperate in his habits. his sense of obligation. cannot group past events correctly. his affection for his family and friends become blunted.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS nounced. Sometimes he acts as though he were slightly dazed or confused. and judgment are being impaired. His habits he does not dress himself completely. at other times as though he were slightly intoxicated. lies The pa- tient may in tell silly and absurd which have apparently no object or purpose. the death of a friend. forgetting the decencies and and that his taste. Often the His account reveals obvious lapses and lacunae. He may may also drink to excess. deteriorate. well.

and it is As a rule. perhaps a faint intention tremor of the hands. physical signs also become evident to the observer. lips. become gradually more and more Little by little the symptoms. heavy. The facial muscles reveal the general loss of tone betrayed by the patient in his attitude and in his movements. If we observe his movements carefully. While the mental phenomena are making their appearance. . are at times quite notice- able and at others disappear. at first. or tongue. Sometimes. we note also slight inaccuracies and slight incoordinations. both mental and physical. or there sional may be an occaaffection tremor or uncertainty in the speech. they are so clearly marked as to attract the attention of friends. its lines less and wrinkles are shallower and clearly marked. there is a distinct diurnal variation. We have already noted that the patient's expression slight fatigue or somnolence. dazed. however. also. these physical signs. and becoming dull. The invasion of paresis is by no means uniform. These variations of progress Sometimes. shadowy and uncertain definite. At times. perhaps a slight and inconstant inequality of the pupils. developed period of the disease. we look closely. As the progresses. we note that the face its folds presents a slightly smoothed-out appearance. gradual.274 MENTAL DISEASES is a deterioration of the moral sense. usually the offence in so silly done and absurd a manner as to lead to early and certain detection. or that he If may be may present an that of unusual also pallor or a heightened color. Faint signs of mental change come and go. until the patient enters into the fully become more pronounced. are quite irregular in their occurrence. the transition the initial is impossible to say just when period has terminated and the established period begun. or slightly confused in the evening. the patient being quite normal or almost so in the morning.

may be the When such an attack assumes. a typical Jacksonian type in a case that has not previously been under observation. only infrequently does it last a day or two. Quite frequently there a loss of power. but sign of the developing disease. disappears in a few hours. should be added that. Sometimes both sides of the body are involved. in the initial period of paresis than epilepti- form. on the whole. the con- confined to one extremity. After a few premonitory symptoms. again. to an ordinary attack of epilepsy may be very save that the convulsion may be longer slower. upon one Less frequently than apoplectiform attacks are seizures is in which the unconsciousness attended by a convulsion. usually an arm. such as sleeplessness. the transition is relatively it sudden or rapid. excitement. from a sudden is loss of consciousness. sustained and the recovery of consciousness much Sometimes a Jacksonian epilepsy vulsion being is closely simulated. epilepsy or apoplexy. no noticeable change of power is subsequently observed. to the surprise of the physician who has been called in and who is not familiar with the previous condi- tion of the patient. may first not only occur during the crass initial period. certain attacks. usually involving one-half of the body. but the paralysis usually predominates side. is consciousness may not be completely rarely it is preserved.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 275 however. suggesting. as here described. often. In the epileptiform attack lost. epileptiform attacks. apoplectiform seizures are more frequent However. as the writer has seen. the patient suffers restlessness. as when be. at other times. of variable duration follows Sometimes a paralysis or weakness such a seizure. as in epilepsy. and. Such attacks may come on and at any time during the initial period. It in the apoplectiform attack the loss quite complete. as in stroke. may supervene. . an ordinary apoplectic Usually this hemiplegia is temporary. The resemblance close.

tremulousness of the lips or of the muscles about the eyes and forehead are striking symptoms. The and lines of the face. as above indicated. about the forehead. distinctly droops or is Sometimes one-half of the face more frequently disturbed by tremors or twitchings than the other. That exceptions to this rule we have already seen. As a of fact. more frequently is noted in the hands. When the patient is asked to show . apoplectiform attacks occur relatively early. form attacks relatively obtain. Finally. we find that it is markedly diminished.276 the situation MENTAL DISEASES may be very puzzling. seen. distinct. epileptilate. they it is may be spasmodic and jerky. Traces of these signs are. Irregularly recurring twitches of the facial muscles. are less pronounced. If Now they are more pronounced. In their absence. as we have already present in the prodromal period. may lack coordina- Again. The face may seem unusually smooth. we test the muscular strength of the patient. Seizures are not present by any means in all cases. As a rule. as already is noted in the initial period. is Tremor. that there is great danger here of error in hasty diagnosis need not be pointed out. Most fre- quently the face which attracts our attention. they may occur at any stage of the disease. when the physical have become well defined. the lips. perhaps fine. the transition from the initial to the estabhshed period may be extremely gradual. slightly puffy. the inference must not be drawn that matter seizures are limited to the initial period. consider that the patient has fairly entered the fully We may signs estabhshed or second stage of the disease. The may be awkward. Again. coarse. and effort elicited or becomes patient's more pronounced upon movements. seizures of any kind may be absent throughout. tion. or intention. as a whole. this labial fold especially true of the naso- of the lines or. on the other hand. and tongue. perhaps flabby and coarse.

dis- tinct ataxia may be noted. and is this may gradually become more pronounced. a difference in the . however. such as observed in tabes may. however. be diminished or entirely is they vary greatly. and in addi- tion to moderate incoordination. the gait also presents some Like the is evidences of spasticity. Quite commonly such a diminution or loss form. and rarely is markedly so. be met with in the ascending or tabetic form of the disease in which the early physical signs may closely resemble those of tabes. but such dif- usually very slight. average case very moderate in degree. as the disease advances. The knee jerks are quite commonly exaggerated. this spasticity in the incoordination. The eye symptoms They nosis. he may protrude it by jerky and irregular move- ments.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 277 the tongue. is noted in the tabetic An ankle clonus is only infrequently present. ataxia of gait of an early sign and suggests the diagnosis locomotor ataxia. If the movements of the arms be examined they If may is reveal a distinct. but. however. they may lost. earliest signs is that of inequality. however. If. are exceedingly important from the standpoint of diag- Quite frequently they occur very early. the patient's usually station be tested by the Romberg method the sway sometimes not at all. as in the tabetic form just men- tioned. Differences in the size of the pupils ference is may occur physiologically. The no gait of paresis is very variable. Pronounced increase of sway. when present they are usually in keeping with other evidences of spasticity. and this true also of the Babinski sign. though not usually a coarse. In a large number of cases. of paresis next claim our attention. The most comand here mon phenomena one of the are those which relate to the pupil. Infrequently. found to be slightly increased. ataxia. The tendon reactions of the upper extremities reveal nothing characteristic. It may early reveal peculiarities whatever.

and this difference be associated with a sluggish light reaction in either or both. but is much less frequent than in tabes. it If associated with a change of the light reflex. has of course special significance.278 size of the pupils MENTAL DISEASES be noted. Myosis is observed. Long before the pupil becomes . and thus may justify the term ameboid pupil. at until the disease far advanced. or sUghtly angled. ally The irregularity. is Mydriasis does not occur. . How significant these observations become when they are attended by a diminished or a sluggish light reaction we will presently see. the same inference the pupil in paresis is is indicated. is present at times and absent at others indeed. An if unusually large pupil all. like the inequality. its may it be oval or ovoid or circumference may be irregular. and size of the pupils are very important. shape. the circle may may be here or there be sHghtly flattened as by a cord. it is usu- changing and shifting. the shape may change while under obser- vation. but the symp- tom of paramount value is change in the behavior of the pupil impaired or lost sooner or later in to light. but when present are usually very They appear to be due to an irregular innervation of the iris. not infrequently irregular in shape. If inequality and irregularity both obtain. The deformities are never gross. present at one time and Again. In the early diagnosis of paresis changes in the equality. Changes in the size of the pupils are infrequent in the early stage of paresis. if the inequality of the pupils be shifting in character. Again. is rare. The hght reflex is the great majority of cases. It absent at another. the inference as re- gards a developing paresis is equally obvious. distinct. the finding suggests paresis in an incipient stage. and the symp- tom is to be regarded as the forerunner of the Argyll-Rob- ertson pupil.

is The reaction to preserved in paresis long after the light reflex However. more rarely. Amblyopia is more commonly observed than amaurosis. but dis- they are not common. or On the whole. Among the physical signs of paresis. more especially of the third. It may exist with or without a diminution of in a suspicious case it consti- the color sense.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 279 fixed to light. Disturbances of the visual fields in paresis is may occur. with progressive amblyopia and changes may be noted. the more likely is is there to be loss of accommodation. Changes amaurosis. such as a hemianopsia. first marked to cause blindness rare in paresis. A . gross changes. exists when the pupils react differently to light such an obser- vation always reaction justifies the inference that in one pupil the light must be abnormal. point of great diagnostic importance. in the Amblyopia. especially turbances. the loss present in both eyes simultaneously. this true of marked Concentric reduction may be noted. fourth. again. fundus changes are exceptionally met with among the physical signs. Indeed. Usually the degree of amblyopia present under such circumstances is sUght. but when present tutes an invaluable sign. gray. various palsies of the cranial nerves may occur. . As compared with tabes such The papilla are relatively infrequent. accommodation is lost. also disappears. is optic atrophy sufficiently Notwithstanding. and. deterioration it become profound. it is noted that the response is lessened in degree or that it is distinctly sluggish or retarded. it eyeground. in the eyeground. white. when the dementia and as in the final bed-ridden period. in cases in which the pupils are equal. The more advanced the case. however. may be pale. either in the pupils or eyegrounds. may exist without any changes may antedate all other demon- strable changes in the eyes.

as dementia progresses. outward or inward rotation is noted. of paresis. so frequently general improvement. preservation of accommodation. appears. palsies and other motor disturb- ances are quite secondary in importance to the other eye symptoms stant. At times slight atactic movements —perhaps suggesting nystagmus and incon- — are present. or striking. the pupil being then inert to all accommo- forms of excitation. e. affec- especially tion. it Very rarely the lost. is to be looked upon as the beginning of the pro- . They may make their appearance at the very beparesis or may occur during the period of the fully These Usually these palsies are not pronounced frequently only a very sUght degree of ptosis is developed disease. and in the estabhshed in accommodation may be added. impairment and final loss of dation. and. period. inequality of pupils. in the latter part of the established period or in the final period of It should be borne in larity of the pupils maximum dementia. g. later. as in a case pupil. with.. inequality and irregu- mind that the may vary considerably from time to time. The irregularity of the an early sign. they are relatively infrequent The usual sequence of the ocular follows: phenomena may be briefly summarized as pupils. ginning of may give rise variously to strabismus. diplopia. On the whole. careful lies. Most or of weakness of rule. keeping with the increasing loss of mind.280 MENTAL DISEASES sixth. may this be observed in the early stage of the light reflex. reported by Bumke. irregularity of impairment of the light reflex upon one or both sides. if impaired and not entirely may be re-established during a period of during a remission. lioss of which is infrequent. at the same time. as a observation required to detect even these are transitory anoma- Quite commonly they and fugacious. and or ptosis. A fully developed Argj-ll-Robertson pupil may be present in the early period.

Elision of letters. or the sentence part. Slight disturbances of speech. distinct aphasic phenomena and phe- nomena due to poverty of thought are added. for instance." ''artilleryman. unfinished." and the The handwriting in paresis also undergoes a change. noted in the initial period. words. the peculiarities of speech are due to ataxia and tremor of the various structures — lips. It is not un- common to use. in examining the speech of paretics. the eyes in juvenile paresis present a symptom group similar to that found in older subjects. broken. The enunciation loses its precision. irregular. as the established period is reached. or syllables may is be haltingly repeated. syllables are slurred. as the dementia progresses. or there is a quavering break between syllables or between words. such as "truly rural. Later. and hesitation." and the like. It be- comes tremulous and errors of spelling and later the patient makes and of grammar. tongue and palate — concerned in articulation. and syllables occur with frequency. especially in the initial or early established period. In and especially earlier in the case. the enunciation atactic. In other words. in general terms. or unintelligible. inert pupils of the terminal it should be added that. Sometimes the patient stops because he cannot find the necessary word. Finally. Con- sonants are pronounced imperfectly. or the is wrong word is is used. it is that paretics whose speech does not as yet betray a gross defect may have both the difficulty in letter "1" pronouncing properly words containing letter "r. while the paper is often . It is noted that when the pa- tient attempts to speak the twitching of the lips and of the facial muscles increases. certain words or phrases found to elicit the difficulty of enunciation. thickness.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 281 gressive iridoplegia of which the Argyll-Robertson pupil is the more advanced stage and the period the final stage. give place to awkwardness.

there However. betrays the delusions of the patient. As the patient approaches the established period. sentences are incomplete. The gradually increasing and progressive dementia may be the only form assumed by the mental symptoms. perhaps true hypesthesias ness. in its course a simple its The simple demented form resembles progressive dementia. and. too. should be added physical that. It is often exceedingly gradual in . as in tabes. emotional expansion. thus. judgment. degree of development. fourth. Secondly. on the other hand. and the microless scopic examination. attain a marked will-power. As a result. the physical signs. be present. third. Amblyopia.282 MENTAL DISEASES smeared and blotted. are added. as we have seen. ever. depressive form. both of these states may alternate itself in in the same case. and amaurosis may. until they. There may be a blunting or psychic indifference to cutaneous stimulation. The examination of paretics reveals if few sensory phenomena. This was demonstrated by Schaefer. as we shall see more in detail farther on. color blindHearing. It smell. are first those of increased intracranial intraspinal pressure. now show great deterioration and the mental state is patent also to the lay observor. simple demented form. the mental symptoms of the initial period gradually like become more pro- nounced. the expansive form. among the interesting facts to be grouped with the phenomena and of paresis. or. paresis the may present the following forms the — first. the personal habits. the percentage is of protein in the cerebrospinal fluid increased. the circular form. may exist. Memory. second. A paretic letter is often disconnected. reveals a more or marked increase in the lymphocytes. and probably taste. other symptoms may be added emotional depression. at other times still. date and signature may be omitted. at times. and. Gross anesthesias are rarely. may be obtunded. observed.

the patient may beUeve that blood has become congealed. of sinfulness. the patients smells.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 283 onset. it appears more frequently among men. that he cannot be saved. however. women. Among women. indeed. are Frequently somatic and spiritual delusions intermingled. the simple demented form seems to occur at a relatively early age. lost his insides. they are rarely successful. Occasionally his hypochondriacal ideas are manifested by gross delusions. although also occurs in a large proportion of is. hallucinations are not prominent. vary constantly. and its course may be so smooth that for a long time It it may remain unrecognized. or not at all. have foul tastes and That the latter are interwoven whole. Finally. are extremely shifting and poorly. that he that he is is growing small. The delusions are multiple. for obvious reasons. that he cannot he has no is mouth. that his eat. they do not . that he has been dead a thousand years. Hallucinations may be present. are Somemade. that that his bones are broken. passing through periods or veritable attacks of fear with painful confusion. he may believe is very wicked. and. systematized. it is of longer average duration than the other forms. or it He may evolve ideas of bodily disease or may be of persecution. may hear voices. less active Compared with the depressive and expansive forms. that his bowels are hopelessly diseased. how- with the delusions need not be pointed out. that he has arms and his legs are gone. that there poison in his food. times attempts at suicide or at self-mutilation though. Some- times the patients become extremely agitated. that he wasting away. or. On the ever. paresis almost as a rule. than in men. The depressive form of paresis is characterized earlier by the fact that upon the advent —or perhaps —of the established period the patient passes into a state of more or less marked mental depression.

The patient . To-day he it worth two hundred thousand. is wonderfully strong. noted perhaps in the initial period. of being everything and everybody that . or Paris. are very variable. Occasionally the exaltation increases to such an extent that the excitement resembles that of mania. of in a frenzy his ideas of owning the biggest ship on earth. now becomes make very their marked. the patient be a woman. or.284 MENTAL DISEASES It appear to play an important role in paresis at any time. millions. that he received is as a to- bequest. or that he an "elegant" singer and player. makes no effort to tell account for his phenomit is enal wealth to-morrow he may us that the result of a it great invention. or is favored by more than the usual number of lovers and It is husbands. Berlin. was never better in his Ufe. upon another day. The expansive form pansive mental state. Delusions extravagant in character The patient believes himself to be the possessor of various quahties indicative of importance. The patient may become extremely noisy and pour out greatness. or the tells morrow may be many is day following he has is forgotten about his wealth and us that he a senator. less Its average duration appears to be than that of the simple demented form and greater than that of the expansive form. she is endowed with great personal beauty. of riches. of paresis is characterized by an ex- The tendency to boastfulness and ex- aggeration. very powerful. and feebly held. characteristic of these delusions of grandeur that they are poorly systematized. very rich. that he that he is a graduate of Harvard. should be added that a large proportion of the cases of the depressive form of paresis are found among women. blessed with an extraordinary nmnber of children. He If has an exaggerated feeling of well-being. of is marrying the queen. is a great lawyer. appearance. a governor.

However. versation becomes more and more owing not only to the anomalies of speech. Finally. he walks at all . like epileptiform or apoplectiform attacks. the patient was for a time depressive and expansive on alternate days. every now and then a patient who period becomes expansive. The third or terminal period Little is characterized by a profound Con- dementia. series of depressive has been suffering from a depressive Occasionally. gradually vanish or recur only in occasional fragments. forms. because involvement of the muscles of the larynx of the chest walls. indistinct and especially to the increasit The and voice sounds hollow. difficult. Toward the close of the if estabUshed period the delusions of depression or expansion. Its duration is shorter than that of either of the other The circular form of paresis is very rare. though rarely. appears exceedingly rare. usually the phases are very short in duration. they are lost altogether. Periods of great excitement are often followed. a and expansive phases may succeed each In one case observed by the writer other.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 285 powerful and great. foul. by little. rough. but also ing dementia. by a marked accentu- ation of the dementia. Pickett has described a case in which an expansive phase of several months' duration was succeeded by a persistent to be depressive phase. however. The expansive form of paresis. Such an occurrence. and indecent. on the whole. It occurs is. some- times only a few days. In numerous ways the patient shows that surroundings is his appreciation of his If more imperfect than ever. the various physical and mental symptoms of the second stage become more pronounced. the more frequently common form among men than among least women. Sometimes he becomes destructive. they have been present. or of the may be and weak.

and the existence of the patient becomes purely vegetative. . and commonly immobile. signs. or flexed over the abdomen. make their appearance. he he lolls forward or to one side. and especially in the earlier stages. The extremities. in many cases severe contractures of both become more arms ad- and legs make their appearance. and he becomes extremely filthy. tuberculosis or some other intercurrent it is infection. or less rigid. the depressive. The legs may become ducted or firmly crossed. usually Finally. Diarrhea. no matsuffers whether the patient from the simple. These physical they relate to the nervous system. herpetic eruptions difficult. if not present before. as far as or the expansive form. mental faculties are completely. Occasionally tremors or twitch- ings distort his features. He fails to is evacu- ate his bowels and bladder. no emotion The pupils are frequently dilated. Other profound trophic changes are the rule. cystitis. the arms are flexed and drawn over the chest. these. have already been considered. while not of prime importance. presents an increased arterial tension. The circulation in the larger number of cases. but they correspond to of the patient. especially in the non-ataxic form. boils. bedridden. perhaps heart failure and edema of the lungs that conclude the scene. — Swallowing becomes increasingly The lost. terminate the picture.286 MENTAL DISEASES If he stumbles and staggers from weakness and ataxia. hematomata. — blebs. it may be. sits in a chair. such as influenza or pneumonia. the latter are emptied spontaneously. His face coarse and flabby and its expression vacuous. becomes either not hopelessly Voluntary movements are attempted or take place without evident purpose. while Bed-sores. visceral It remains to briefly summarize the symptoms. disease of the kidneys. merit a brief consideration. The ter physical signs of paresis are of course the same. the patient unequally so. or. or almost completely.

the skin unusually dry or unusually moist. Sugar is Early in the case the urea and chlorids are in- creased in amount. In bedridden The cases. the rhythm is may be disturbed. and doubtless also due to the defective innervation of the intestinal tract. and occasional bleeding or hemorrhage may be observed. not is much modified. later they are diminished. urates. sometimes a Cheyne-Stokes respiration Digestion is. fat. the swallowing of the food in bulk. is occasionally excessive local sweating observed. and thence onward. The found urine only infrequently presents albumin. especially about the forehead and temples. The drooling ob- served in advanced cases increased secretion. Sometimes it becomes darker. last stages and other solids undergo diminution as the of the disease are reached. well preserved. however. rarely slow. however. The saliva undergoes no is special change. Later on. The perspiration is. The histologic examination of the blood . for instance. the pulse-rate slightly increased.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 287 The second sound is of the heart is accentuated. respiration presents no special change. however. as he becomes he increases in weight and accumulates a soft and flabby period is As the terminal approached. The phosphates. a progressive loss of weight again occurs. and sometimes normal. owing to imperfect mastication. the patient initial loses in weight during the period and during times of expansion and excitement. In the late stages the skin may become sticky and greasy. Mucous colitis. less active. not necessarily connected with an Other things equal. Late in the case. rarely. over one-half of the chest or back or one-half of the trunk and body generally. simulated. Some- times. as a rule. ulceration of the bowel. as a rule. however. diarrheas make their appearance.

disturbances occur in paretics.288 reveals MENTAL DISEASES nothing characteristic. these The skin bruises very easily. and which is identical in character with the perforating ulcer met with in tabes. persistent erythema. and slight swellings after insignificant pres- sure or traumata. must find its explanation in some visceral or local complication. such as local flushing. in the great majority of sure cases. They due to presnutrition. with few exceptions. Rise of temperature. in paresis remains. tion. The temperature normal. herpetic eruptions. especially a decided rise. In this connec- we should mention especially the perforating ulcer now and then seen on the ball of the foot. there are other evidences of trophic changes furnished by the skin. the extravasais very marked and accompanied by a certain amount . simple vasomotor disturbances. Due to the greatly lessened resistance of the tissues. upon tissue in a state of greatly lowered That trophic in influences. and ulcers. Some- times punctiform hemorrhages and at other times purpuric spots and blotches are present. is however. marked dermography. such as blebs. play an important role some cases suggested by the rapidity and suddenness with which they every now and then appear. circumstances bed-sores form with great Naturally they occur most frequently in the latter part of the second and in the terminal periods of the disease. Finally. A rise of temperature generally occurs at the time of and following a convulsive or apoplectiform attack or a period of agitation and excitement. oc- curring at other times. Besides. are doubtless. and under readiness. be noted. There may be a moderate degree of leukocytosis with some reduction of the hemoglobin. indeed. sub- cutaneous and other ecchymoses are often met with. Among these we note. however. various trophic first. cyanosis. tion is Sometimes. Slight fluctuations may.

and metrorrhagia. knees. at times. Similar deformity of nose. erosion of the cartilage. the condition is identical with the arthropathies met with in tabes. Here extravasa- tion of blood takes place into the fibrous tissue and skin of the auricle. similar occurrences would appear that may take place on other serous surfaces in the subdural space and is into other organs. though rarely. also. blood is noted in the urine.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 289 of swelling. In the terminal stages. or angioparalytic phewith. hemorrhagic extravasation may occur on the surface of the It pleura or into the substance of the lung. hem- orrhage from the bowels. may occur. there may be general muscular wasting. and they also may be the seat of hematomata. also. That they occur frequently shown at autopsy. other changes may be noted in the muscles. true mus- cular atrophy. The and long bones generally. thus. and destruction of bone. sometimes it is very extensive. frequently become very blows result in fractures. for example. when they constitute a so- called pachymeningitis ha^morrhagica. and we may observe epistaxis. especially in the later stages. hematemesis. is nomena met hematoma of the ear. fluid into exudation of the capsule. The bones ribs also may be the seat of trophic changes. and elbows. Independently of these. hematomata now and then involve the In paretics the muscles also bruise very easily. the symptoms are There is typically those of the Charcot joint. about the ankles. as. so that slight falls or Trophic changes in the joints are also occasionally met with. doubtless dependent upon changes within the spinal 19 . popliteal spaces. due to lesions of the cord. and. like the latter. the change being entirely without pain. followed by more or the ear. At times. The mucous membranes also present evidences of a weakened vasomotor condition. Among the most interesting trophic. Subsequently less re- absorption takes place. brittle.

thus. Remissions. the invasion may be irregular. MENTAL DISEASES As might be expected. The tendency more of late years. the course of the invasion ous. to intents. to produce if lying upon the ear vessels sufficient an othematoma. perhaps faintly. Finally. is however. and the patient be appar- ently well for weeks or even months. Rate of Progress. when not only the nerve-centers but the tissues generally have deteriorated. the initial —The duration of period of paresis cannot. be It averages it definitely fixed. may recede. for obvious reasons. are insufficient to produce such results in a state of health. diseased. similarly. so-called. for normal occurrences. every-day traumata. when they may again appear. following the teaching of von Gudden. It may. trophic changes. are practically limited to the advanced stages of the disease. the nerves. sufficient to if and tissues generally must be is tripping over a rug or it is turning in bed inference break a thigh bone. in practice be impossible to fix of the disease. the Again. usually slow and insidi- A patient all who betrays suggestive symptoms in the even- ing may.290 cord. so-called trophic phenomena and hema- particularly the surface changes tomata. but are met with in a not insignificant percentage of cases. convince us that. A moment's reflection will. symptoms having begun. therefore. somewhere between one and three years. Duration. has been to ascribe the of paresis. in the tabetic form may be much is longer. upon the beginning The tendency to the remission of symptoms may be evident . As already indicated. Doubtless the truth midway. exclusively to trauma. a fair that the bone lies has undergone a trophic change. Charcot joints are not common in paresis. be normal the next morning. they are more frequent in paresis of the ascending or tabetic form. the so-called tabo-paresis.

the patient in an improved condition. an unwillingness or inability to realize that he has been ill. well. is At the time of a remission. in initial period. draughting. Further. a remission occurs in the or before the established period has been fully entered. Well-marked remissions occur. and that the phythe pa- made an error of diagnosis. be complete or nearly Under such circumstances the patient may resume avocation like his daily — clerkship. he has not made a recovery. and greater or less degree. remissions of a year some- what less so. with changes in the tendon reactions and the pupils. the degree of im- provement is remarkable. if Every now and then. and the — for Further. but also in the established period of fact. and those of several years quite exceptional. various symptoms are observed which show that. symptoms may. are. A feeling of well-being. there are very As a matter few cases in a which remissions do not at some time or other occur. his but also sometimes the patient shows improvement for a few clays or a few weeks only. in degree. Sometimes the change is is so great that the friends believe that he sician has tient. a tendency to plan a little too extensively and enof further care thusiastically for the future^ an intolerance or medical advice. physical lessened. ever. professional work. howinitial period. to say the least. though improved. a time. more frequently . if the remission occurs in the established period the persist. the recession of mental so. signs Tremor and speech and so it is difficulties are but still in evidence. is His delusions disappear. his memory better. suspicious symptoms. On examining however. for months and even Remissions of three or four months' duration are quite common. time being. remissions not only vary greatly in duration.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 291 not only in the of the disease. at others years. on the whole. for the indeed. and he is again in closer touch with his sur- roundings and with his affairs.

life. dicated. if be added that. the dura- tion of paresis on the average. be kept under some well. in the simple demented form. but always temporary. is Among these. tend to is course. all factors that tend to quiet the patient. though infrequently. or the occurrrence of periods of marked excitement and agitation. such as apoplectiform and epileptiform seizures. Because of the temporary character of a if remission. especially . Fourth. greater in women than in men. a number of factors fluence the duration of paresis. greatly hasten the course of the disease. Third. Second. They are infrequent when the second all in period is well established and do not occur at the third period. Finally. the degree. all and shortest of all in the expansive form.292 in the MENTAL DISEASES expansive form and somewhat more frequently It should also among men than among women. possible. greatly influenced by the occurrence is. in illness. trauma. somewhat shorter in the depres- sive form. Finally. of all cases is between two and three Cases are occasionally. as already inIt is longest the form which the disease assumes. such as sanitarium or asylum prolong its care and nursing. factors of a disturbing character. or later. rare instances. fracture. in- degree of observation even when he seems most As the reader is by this time aware. as has already been indicated. remissions are relatively frequent in the initial period and early part of the established period. the patient should. a remission follows some acute the latter be one confining the patient to bed among these may be mentioned erysipelas. Sooner symptoms reappear and usually in an increased and quite frequently the affection subsequently pursues a more rapid course. prognosis as to duration of remissions. The average duration years. met with . remission. or abscess. is The a time of shorter or longer improvement.

A is number of paretics thus die before the third period reached. To the consideration of this interwill return in and important subject we Suffice still it the section on Treatment. Sometimes. Death may fection. because of the uncertainties of the period. should be added. it fifteen. This is in cases which begin with spinal symptoms and late. if writer. a gastro-intestinal attack.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 293 in which the disease pursues a furibund course. also occur in paresis is from some intercurrent af- Particularly this liable to happen during the second period. may given cut short the disease. the duration exceedingly great. here. not unusual in again. too. may be much greater is than at first appears. Whether the introduction of salvarsan has brought about a change remains to be seen. alienists who some cases arrests the prog- and also that a larger number of remissions are observed under esting its use. also. to say here that in the observation of the fatal. that this is invariably true . need hardly be added. Prognosis. — It has for life is many years been held that the prog- nosis as regards uniformly unfavorable and that to this rule Certain it is there is no exception. ensues during or follows an apoplectiform or an epileptiform seizure. of the now and then presents a history of unusual re- Ten. . Paresis. An influenza. There are some believe that salvarsan therapy in nosis of the disease. and even more years have been ported. Death now and then. of all diseases. paresis is one of the most not the most fatal. a pneumonia. of cases in is it which no treatment has been instituted equally true of all cases treated by the older methods of mercurials and iodids. that cases of such anomalous length are usually open to question. which the mental symptoms appear relatively ordinary form every duration. initial the actual duration. the patient it dying at the end of a few months.

in exudative syphilis of the cord the picture that of a paraplegia in which spasticity and to a less extent ataxia are the dominant features. syphilis of the vessels and membranes and parasyphilis. possibly optic neuritis. e. presents. can no longer be maintained. somnolence.294 Pathology. mental symptoms are absent or practically is Again. other things equal. the thought naturally suggests itself that the distinction formerly made between i. suffice is to say that in exudative syphilis of the brain the picture headache. which are by a diminextent of it the outcome of the interference of nutrition caused ished lumen or occlusion it of the vessels and to a less pressure. e. both the motor and sensory . but which have a profound pathological With the discovery of Noguchi of the actual presence of the spirochete in the paretic brain. These symptom groups. the subject of syphilis of the nervous system as a whole. it that of may be of without hemiplegia crossed or so. though briefly. palsies of cranial nerves with or ipsolateral. However. it does not follow that it nervous syphilis is the same. it will Secondly be necessary to review many facts clinical in their nature significance. while diseases of the nervous system resulting from the infection of the spirochete fall all properly under the caption of syphilis. At the same time there of tabes are slight sensory losses thesia. nor does follow that the clinical distinctions previously established can be abandoned. while or. gummatous infiltration of the vessels and membranes or syphilis of the exudative form as it may also be called. special symptom groups with special possibilities and probabilities in prognosis.. would be out of place to rehearse here. — not the retardation —merely a hypesphenomena are Further. is necessary that we should first consider. ?. Syphilis of the vessels and membranes of the brain and cord. MENTAL DISEASES — In order that we should entertain clear concepit tions as to the nature of the pathological processes at work. paresis all and tabes..

Thus. infiltration of the vessels ical and membranes Clin- observation has not only enabled us to distinctions it make broad and symptom fundamental groups. if the writer were to trust his own experience entirely. one limb is 295 always more affected than the other. shoot- ing. is often difficult is to elicit. slightly lessened delayed micturition. he would say invariably wanting. are present. is mu- cous patches. often denied. Paresis. fact It is this which has led physicians at times to speak of paresis and is tabes as the outcome of "mild syphilis. a history of secondary symptoms. in brief. and and quite comsymptoms. and falling out of hair commonly wanting in paresis and tabes . while it is quite the exception in exudative cerebral and spinal syphilis. in parasyphilis the history of the e. The picture is due primarily to gummatous of the cord. it is and often uncertain. almost equally true of tabes. sore throat.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS unequally marked in the two extremities. presents the picture as already described. . How in their greatly exudative syphilis of the brain and cord differ symptomatology from that of paresis and of tabes need hardly be pointed out. eruptions. but between these cardinal has also taught a significant lesson as regards of the clinical histories the patients. There first is also a history of a transient bladder disturbance. of the primary lesion. every physi- cian of experience original infection. ing with this a search lesion is In keep- upon the genitals for scars of the initial almost invariably met by failure in both paresis and tabes. Particularly this true of paresis. or other pains. monly spontaneous disappearance Finally. as we have seen.." a designation which singularly inapt when applied to affections which are attended by gross and permanent destructive changes. Again. of a gradually oncoming and slowly increasing dementia. there is of the sphincter a conspicuous absence of lightning-like. knows that i. then lastly vesical control. Certain physical signs.

inequalities. infection. the Argyll Robertson pupil. acquire some quality which especially favors the development . and other symptoms matous. difference in the character of the It is difficult. and by Erb. the incoordination. and to this a sixth. on the other grounds. but that both suffer from paresis. slight modifications of gait. them the outcome of a general. Certainly it that at times the germs of syphilis undergo some change. Similar instances have been recorded by Nonne. while the remaining two presented very suspicious symptoms. This peculiar clinical history suggests a possible. ported an instance of seven glassblowers all by the same mouthpiece.296 MENTAL DISEASES differ largely in and these not only syphilis of the kind from those of exudative membranes and definite. irregularities. to interpret the suffer cases in which both husband and wife It is from paresis or in which both suffer from tabes. and tongue. lips. vessels but also in being less clearly marked and There are present a variable intention tremor of hands. and infrequently transient. gummatous The disease of the vessels and membranes lightning-like pains. marked fugacious pareses all of of the cranial nerves. a parenchy- destruction of brain tissue. sluggishness or fixation of pupils. likewise paretic from the same source. In tabes the symptom group also differs widely from that of of the cord. dis- and the Argyll-Robertson pupil form a well-defined and tinctive clinical picture. of whom five were attacked either by tabes or paresis. quite startling to realize that one of the conjugal partners does not suffer from exudative syphiHs of the membranes and vessels and the other from paresis. transient apoplexies slightly or hemiplegias. Morel-Lavallee and Belieres five have reported an instance in which men infected by the same number Ramadier added Brosius has reinfected woman all became paretic. would seem by Marie and Bernhard. an atactic speech. if not a probable. the loss of reflexes.

as Mott has suggested. but of a toxic condition. or it may be that. "there may be varieties of spirochetes as there are different varieties of trypanosomes. the quantitative reduction of mind. Whatever the paresis facts as to the character of the spirochete of may be. proper to infer that they are due to organic changes. At least this inference is justifiable in all cases except perhaps those of the ascending or spinal form. Here it appears to give rise to toxins. is such a change as might That. physical signs have When Again. in turn. and in another by expansion. It is the actual mental loss. to antitoxins. the added mental phenomena which in one group of cases manifest themselves by depression.. e. Autopsies in cases dying during the established period and . very early period structural changes are absent in cases proved by autopsies which have died at this period from intercurrent disease or accident. the germ is found deeply placed in the brain substance. as might be expected. made their appearance it is. the morphological character of which would not permit of differentiation. a destruction of tissue. and the latter. predominating. of course. also point to a toxic condition. is accompany the varying action in the of toxic agents." To the writer the clinical evidence points strongly to the existence of a special strain of spirochete as the cause of paresis. It is extremely probable that the very earliest symptoms of paresis are not the result of organic change.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 297 of paresis. the latter are frequently found to be slight and inconsequential. which indicates an organic change. The mere fact that in the initial period there may be a complete recession of symptoms indicates that the change in the nervei. in the cortical tissue. in cases dying during the initial period in which organic changes do exist. centers is as yet functional. indeed.

adherent con- to the dura.298 MENTAL DISEASES and quite constant find- in the terminal period reveal striking ings. It is noticed. we attempt we per- we find that it is not only thickened. it is observed that healthy brain. When the brain it it is removed and placed upon the its table. cysts are formed. may be yellowish or reddish. often firmly thickened. If The pacchionian bodies are increased in number. such for- mations are sometimes spoken of as arachnoid the skull is cysts. as of the pia arachnoid are everywhere with are the gaping sulci. and here and there is may have disappeared. also observed that the calvarium removed with it is more or is less adherent to the dura. difficulty. too. but adherent to the subjacent cortex. or more or less evidence of organization. that the calvarium is much It thickened. or it by a thin new-formed membrane and fluid. so sist in much so that. The is pia this arachnoid is opalescent and infiltrated. The dura. on opening the skull. covered taining clear. and. When opened it is also noted that an unusual amount of cerebrospinal fluid escapes. its inner surface often presents the condition known as pachymeningitis haemorrhagica. does not retain shape as well as does the it is sags and flattens. reddish at times deposits. if the attempt. often small and again quite large. obviously softer than normal. Repeated exudations of blood upon its surface have been followed by thickening. particularly noted along the sides of the veins. often the diploic structure has been it is much encroached upon. We are also impressed by the fact that the convolutions are sulci are markedly small and atrophied and that the gaping. so. Naturally. they reach their greatest development in cases d^dng in the terminal period. Here and there the . to remove the pia. filled wide and The meshes fluid. much when it is opened and turned back. the cortex is torn off along with the pia.

The ventricles are found dilated. of proliferation of the neuroglia. while the ependyma is rough- ened by granulations. its cellular it is found to be thinner and to have lost some of it is elements. Of course the evidences of atrophy and loss of substance are. and Like the nerve cells. and true alike of the radiating fibers of the tangential fibers which enter the cortex and stitute its which con- outermost layer. pons. it is found to be much less heavy than normally. If parietal we incise the brain.8 ounces. while the granulations have their origin in a proliferation of the neuroglia. As a whole. The nerve cells have undergone granular and pigloss mentary degeneration. the last-mentioned changes are particularly pronounced in the fourth ventricle. atrophy. the author found the average weight of nine male paretic brains to be only 41. while the average weight of four female paretic brains was only 37. and the surface of the superjacent pia may present at such places the in the appearance of covering a cyst. of cell processes. other things equal. Everjrwhere there are evidences here and there large. frequently impossible to trace the various layers of the cortex. Changes similar to those noted in the cortex and white matter are noted in the basal ganglia. more pronounced in patients in whom life has been long- est maintained. many . as by loss of substance. If weighed. the crura. we find that the cut surface is more moist than usual. the changes convolutions are more marked in the frontal and regions than elsewhere. indeed. and cerebellum. the nerve fibers have undergone atrophy this is and destruction.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 299 cerebral cortex is depressed.1 ounces. The endothelium the brain be seems to have disappeared. thus. If the cortex be examined microscopically. and here and there lying loosely in we see small vessels what are evidently dilated perivascular spaces.

tor. we find evidences of descending degeneration in the pyramidal tracts. especially which spasticity and perhaps late contractures have been features. with lymphocytes. Rarely does . tance. the family docfirst. other things equal. Diagnosis. in other cases. The vessel walls and the perivascular spaces are densely cells. in which a tabetic symptom group was terior early present. infiltrated with nuclei. again. especially be recognized sufficiently early. There are commonly certain suggestive facts associated with the manner in which the case comes to the attention of the physician which.300 branched MENTAL DISEASES glia cells are seen. In the cord. the patient in the early stages of paresis is usually brought to the physician by relatives or friends. we find changes in the pos- columns. —Our increasing knowledge of the etiology rise to and pathology of paresis has given it the hope that perhaps its may be possible of cure or at least of being arrested in if it progress. who sees the patient and it often depends upon the is alertness and acumen of the latter whether an early diagnosis made. of course. also The peripheral nerves may reveal changes similar to those found in tabes. the neuroglia and connective and changes in the vessel walls. those reveal dura less frequent. In many cases. assumed a great impor- It is. changes in the pia are more or in the less evident. therefore. increase of tissue elements. the practising physician. and plasma Elongated rod-like cells are also found in the neighborhood of vessels. the so-called spider-cells. The early diagnosis of paresis has. The cord substance may degenerative changes. Not uncommonly degenerative changes lateral are found in both and posterior columns or irregularly evident in various portions of the cord. should excite the suspicions of the latter. Similar changes are found in the basal ganglia and cerebellum. though these are rarely as in those in marked as in the brain. First.

it is the relatives or who detail the symptoms. Of course as soon as physical pearance. is has not become altered so as to suggest that the patient a changed man. of the neurasthenic betrays no somnolence . in marked contrast to that of the neurasthenic patient. The is ill. 271) are elicited. He is commonly regarded by nervous or suffering is from nervous prostration. Secondly. and little by little the sympparesis toms already detailed as characterizing the beginning of (see p. not the patient.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 301 he come of his own friends initiative. friends are never the ones to discover that the patient listen to his and indeed quite frequently complaints with is impatience and incredulity. They give an account of changes which they have noted and of which the patient himself has not been cognizant or to which he has paid no attention. but at such time . who not only seeks the physician's advice himself. that he no longer attends to his business carefully nor does his work as well as formerly. about the patient and not by the patient himself. but also has at his tongue's end a long list of complaints. when his case studied by the physician. Again. tell The friends of the paretic patient will a very different story. however. the diagnosis is signs begin to make their ap- very readily made. The signs of ill health are first observed by those Indeed. the physical appearance . his features lack none of their folds. Often they maintain that his appearance and manner have changed. accustomed expression there is no lessening of the It facial it is still the same face to friends or relatives. it is found that he presents the symptom group of ready exhaustion so typical of neurasthenia without the slighest change in mental quality. Finally. all of them symptoms by no means his friends as being frequent. the latter does not actively complain unless there happen to be present tabetic or neuralgic pains or perhaps attacks of headache. His conduct.

which is positive in about 90 per cent. and when larger quantities (e. Four reactions are to be studied . third. commonly spoken of as lymphocytosis or pleocytosis. g. second. in the cerebrospinal fluid. The third reaction.2 c.— 302 MENTAL DISEASES is the transition from the prodromal to the estabhshed period already taking place. may be briefly stated that the Wassermann test depends upon the presence of antibodies in fluid. which as we have already seen is positive in almost 100 per cent. Complement binding a reaction which was discovered by Bordet and Gengou sists in — conif the fact that when an antigen and is its corresponding antibody meet the complement held fast. in 100 when 0. termed by Nonne the "Phase I" and reaction. the Wassermann reaction in the blood.) are used. globuHn. the determination of the presence of an excess of protein. in every case presenting the slighest suspicion of paresis. and independent of any clinical history. the serum of the blood or in the spinal It will be recalled that the body which results from the union of an antigen and antibody is composed of two basic substances. This fact can be the demonstrated by the addition of a hemolytic system.c. Obviously it is the imperative duty of the physician. 2 c. of fluid are used. the presence or excess of lymphocytes other formed elements in the cerebrospinal fluid. complement has been held fast there is no hemolysis. one the ambo- ceptor and the other the complement. For the benefit of such of it my readers who are not in touch with laboratory methods. fourth. Various methods . depends upon the fact that the cerebrospinal fluid normally contains merely a trace of protein substances and that any appreciable increase has a pathological significance.^rs^...c. the Wassermann reaction in the cerebrospinal fluid. the globulin test. Here we have happily a means of diagnosis of great value. to insist upon a serological examination.

. cases of tabes are met with in which an increase of lymphocytes is not present. In both paresis and tabes the increase is usually decided. and at times into the hundreds. fluid The number is estimated as normal to the cerebrospinal given as five to six thal) or eight per cells at variously the most per c. eighteen or twenty-three per c. The borderUne count is placed by Kaplan as high as nine to fifteen per c. On the other hand. (Fuchs-Rosen- c. the fluid becomes turbid three minutes after the addition of the is ammonium sulphate solution.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 303 have been devised for the performance of this Suffice it test.. The greater the increase. which it would be out of place to discuss here. as Kaplan points with markedly staining The cell counts may range as high as fifty or sixty cells per c. above the normal. These are much larger than the lymphocytes Their significance is. pathological conditions this Pleocytosis is Under number may be greatly increased. the reaction evidently we have here to do with Similarly in cases of paresis very chronic and inactive cases. long stationary or very slow in course ing comparatively little we may find counts range. do not contain them. It should be mentioned that Alzheimer and others have placed on the finding of plasma cells in especial importance the cere- brospinal fluid. in- always indicative of meningeal irritation or flammation. the more active the pathological process. The fourth reaction depends upon the fact that normally the cerebrospinal fluid contains very few formed elements. the Of smaU lymphocytes largely predominate. many cases of paresis. g. these. (Kaplan). to say that the "Phase I" reaction of Nonne consists saturated in the addition of a ammonium If sulphate solution to an equal quantity of spinal fluid.

we receive from the laboratory a negative Clearly. may turn the scale. the clinical signs of paresis are indubi- tably present and yet serological report. in the great in the blood majority of cases. The negative reaction indicated by a salmon red. This test depends solutions upon the principle discovered by Zsigmondy that of electrolytes precipitate colloidal gold. the old therapeutic test of tolerance to the iodids and mercurials may there be tried and. of antibody formation. occasionally absent both in the cerebrospinal fluid. This fact is in re- keeping with the findings in tabes in which the Wassermann action in the blood may be absent in about 30 per cent. that of Kaplan. further.304 Finally. i.nd then. if However. the case obviously cannot be classified under neurasthenia. we are left sadly in the dark. that under given conditions. and in which. which available. is if successful. of arrest of progress. proteins in the presence of electrolytes. However. while the various . such a condition means a relative degree of quiet and. g. do the same thing. another laboratory test. This is the colloidal gold test. the MENTAL DISEASES Wassermann and reaction though present. or to the admirable articles of Fordyce.. of the cases and spinal fluid. will e. is the reader referred to special works upon serology. in the absence of electrolytes. in a suspicious case of paresis. The test is performed with ten dilutions of spinal is fluid. These facts have been applied by For the details in- Lange to the examination of the spinal fluid. and that they inhibit precipitation. for the time being. may also be wanting occasionally in the cerebrois Obviously the absence of the reaction con- sonant with a lessened or arrested activity of the spirochete and a consequent absence a. Every now though rarely. a case in which neither the mental nor physical signs are such as to permit of an absolute diagnosis. Of course. as is we have seen. for stance. psychasthenia. e.. or other neurosis. may be applied. on the other hand.

It was soon little if at all into the cavity Various attempts were then made to apply the remedy directly by means of intradural injections. of salvarsan The tions employment by intravenous injec- made little if any impression upon the course been pointed out. the possibility of error should not be lost sight especially in the performance of the all of. Paresis. to it is. original is an affection which. Sicard and Lapointe. therefore. for instance. when invariably fatal. definite more be upon the and positive value of the physical signs of paresis. emphasis should once To this series now come laid to be applied. gray. precipitafirst tion of the colloidal gold occurs regularly in the four to eight tubes with decolorization or a turbidity. and 20 others. in which remedies which might be efficacious in exudative syphilis of the vessels little effect. Robertson. Wassermann if test. blue. to colorless. is or progress of the disease. at least. . While the great importance of laboratory reports sliould not be under- estimated. to consider the treatment of paresis in the present section. must stand. as has a parenchyma- tous affection. and membranes. of changes the term "paretic curve" has Finally. Treatment.- — Contrary to the plan pursued elsewhere in this it volume. While positive statements as to the results achieved do not meet with general acceptance. have been made to gain control of this disease. renewed or. the writer has thought wise. blue gray or According to Fordyce. because of its highly special character. and one. Under circumstances the clinical evidence. notwithstanding. would probably have but learned also that salvarsan diffuses of the dura. by Marinesco.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 305 degrees of precipitation are indicated by change of color in the tubes from red to red blue. a more or less to make durable impression upon its progress. efforts Since the introduction of salvarsan. in paresis. positive. lilac or blue. justifiable in employ any means at our disposal untreated.

of Forty blood are withdrawn. are diluted with an equal or twice the amount then injected intradurally. lies The bed patient either upon his side or sits upon the edge of the with his back to the operator. of blood are withdrawn from a vein.306 but it MENTAL DISEASES was the method In this of Swift and Ellis which finally came into vogue. For reasons which will become apparent later. This is allowed to stand . After an interval of thirty to forty minutes. Swift and Ellis believed that the blood contains a of salvarsan at the maximum amount minutes. opinions. Ten twenty cubic centimeters.c. is or more. method the patient receives an intravenous injection of salvarsan or neosalvarsan. the patient placed upon his back without any pillow under his head and the foot of the bed elevated some ten or twelve inches. and then centrifuged at 3000 revolu- tions for a period of half an hour.c. The rule that we have followed in my own c. Before making the injection. salvar- Ogilvie modified the Swift-Ellis method by mixing the san directly with the blood-serum outside of the body. or fifty c. some 40 c. service to allow the fluid to escape until all evidences of increased pressure have subsided. After giving the injection. are divided and some physicians wait only twenty The blood withdrawn natant is allowed to stand over night. however. I have not repeated this procedure more often than once it is in ten days or two weeks. This position patient is is maintained for some three hours. end of an hour. and frequently wise to allow a still longer interval to elapse. after which the allowed to assume a more comfortable position. is Usually the intraspinous injection given about twenty-four hours after the intravenous. and at times until 60 or 70 have been drained is off. considerable cerebrospinal fluid should be permitted to escape.c. say some 40 c.c. The serum to is then inactivated at a temperature of 56° C. the super- fluid is pipetted off. of salt solution.

Opinions treatment. again. The Swift-Ellis method has been employed very extensively . by salvarsan or neosalvarsan. about six ounces. Mott is of the opinion that general paralysis has not been cured or even greatly benefited istered. milhgram of salvarsan. of 56° C. To this is then added one-fourth in sterile which has been dissolved way. on the other hand. the supernatant fluid is then pipetted off and thoroughly centrifuged. Cotton further states that the number of remissions occurring under salvarsan is very much greater than those which occur spontaneously in untreated cases. The blood. serum may Dunton and Sargent. state that the duration of cases treated with salvarsan is less than normal. This is water and neutralized in the usual is thoroughly mixed with the serum and then the serum at incubated for an hour body temperature and later inactivated at c. a temperature injected. One-fiftieth of a grain of bichlorid in solution then added and the mixture well shaken to prevent precipitation. Another method has been devised by Byrnes which the serum is consists in adding bichlorid of mercury to instead of salvarsan. in the Ogilvie is withdrawn and the serum prepared as method. more serum being added if necessary. for instance. are that the patient The objections to this esthetized method must be an- and trephined.c. points out the importance of treating cases in the early stages and that treatment must be persistent. A method which has been developed by Wardner Ellis is that of injecting serum obtained directly by the Swift- method beneath the intracranial dura. differ as to the efficacy of the various methods of Cotton. believes that salvarsanized bring about definite arrest in paresis. no matter how admin- Cotton. Usually about 10 also treated of this serum is The patient is by means of ordinary intravenous injec- tions of salvarsan.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 307 three or four hours.

308 in MENTAL DISEASES clinic in my own given cases with decided improvement. forbids a too sanguine expectation. Re- missions of more or less length have been established. the fact that extensive remissions neously and that untreated cases of paresis occur spontaa very long may have duration. As an early result of the treatment. in paresis. our great surprise this method was also followed by a fall in To the lymphocyte count and the patients themselves improvement. effects of results. must. Later they instituted simple spinal drainage alone. The im- provement was most in tabes. In the asylum cases the results of treatment have been far less evident. and in a few instances these have proved of such long duration that they suggest that perhaps a permanent impression has been made. There is. however. that improvement has been most pronounced in cases whose condition was not so advanced as to necessitate asylum commitment. Gilpin and Earley tried in my clinic simple spinal drainage. However. be exercised in drawing our inferences. Earley and myself treated by intraspinous in my service a number in the usual of cases injections of unsalvarsanized serum. in the we frequently note an improvement mental symptoms and especially a reduction Great caution in the pleocytosis of the cerebrospinal fluid. of course. striking. late The Thomas B. significant. in It is perhaps my own experience. a relief for the time being it is of the increased intradural pressure. as might have been expected. but very probable . also showed the Finally. and with truly remarkable At first they practised spinal drainage before giving the intravenous salvarsan injection in the hope of favorably influencing the diffusion of the salvarsan into the dural sac. but was also very evident The patients are put to bed and drained of every possible drop of fluid about once in two weeks. the serum having been prepared and inactivated way without the previous intravenous injection of salvarsan.

of course. has inoculated his patients with cultures of erysipelas. a similar result. of the brain as well. cause him to react. parallel to the results of the Bier in surgery. and in the resulting reaction has noted the appearance of more or less pro- nounced remissions. taking advantage of this fact.— MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 309 that drainage results in a kind of lavage of the dural space. therefore. facts are of the very greatest significance The above and they are in keeping with the occasionally achieved force —for rest the time being — brilliant results by methods alone. Further. also to eliminate the factor of the effect of the mere trauma of the intradural methods. It would appear. we have here a Finally. If the pressure of the cerebrospinal fluid that the vascularity of the cord will will be increased. Intercurrent infections have. other things equal. it will follow less be diminished. as past experience has shown. as is we know. there must normally be a balance between the bloodpressure in the vessels within the cord and the pressure of the cerebrospinal fluid. Pilcz. stimulate the resistance of the patient. by methods which his defensive up the nutrition of the patient and stimulate . is rapidly replaced. Probably the results —often truly remarkable method which follow radical spinal drainage are to be attributed to the improved nutrition following this increased vascularity. and to be better for a time. Relatively slight and sometimes more pronounced traumata. it should be added that we have never in either paresis noted any untoward results from spinal drainage or tabes. at times. In keeping with this there also a fall in the lymphocyte count. That the diagnosis should definitely exclude brain tumor and abscess It is difficult goes. its blood than normally be able to enter vessels. In other words. that the rapid withfluid will drawal of the cerebrospinal in the vascularity of the be followed by an increase cord and. without saying. because the spinal fluid.

by diarrheas and other toxic symptoms.of the mercurial may be followed by a serious involvement of the gums and teeth. Indeed. is must be borne in mind that the resistance to mercury greatly diminished in a patient under salvarsan therapy. It is evident. and perhaps Regarding the iodids. Only such a remedy as would be readily its diffusible through the tissues and which would exercise toxic action for in- upon the germ without injury stance. would seem. especially latter. reactions. acts in malaria to the host it —as quinin. —would fill. in the great mass . CEREBRAL SYPHILIS Cerebral syphilis of the exudative form is not accompanied by any special group of mental symptoms. that the treatment of paresis is still most unsatisfactory.) whenever practicable. in order that the patient should receive the benefit of every possible means at our command. and that the too free use. is The germ is deeply embedded in the nerve substance and practically be- yond our reach. (See Part IV. impossible to paretic practically make a pronounced mercurial impression upon a relatively sensitive and yet under salvarsan he becomes to the action of the remedy.310 MENTAL DISEASES It is. This is one of the most remarkable facts Ordinarily it is attending the use of salvarsan. is it this however. it is important that in the intervals of the salvarsan therapy he should be thoroughly treated with mercurials true of the mercurials. the conditions presented by the problem of paresis. Finally. when all the facts are considered. It is probable that the improvements observed are due to the favorable action of the various medicines upon such of the spirochetes as are accessible in the membranes and vessels. important to combine the salvarsan or other special method of treatment with a systematic course of rest treatment in bed.

together with special symptoms dependent upon the sites of lesions. lips. they are not is cured by treatment. Notably atactic this the case with the tremor of tongue and of the the speech. may An Argyll-Robertson i. The so-called cases of pseudoparesis are rejected by the writer as not belong- ing to syphilis of the exudative form. two Such cases are. Perhaps we have to do here with a double infection. and possibly optic neuritis. be. somnolence. in accordance with an increasing experience. may be that epilepsies are present owing to involvement of area. e. with other frank oculomotor palsies. The patient presents the general symptoms of headache. The resemblance of such cases to however. are The physical signs of the affection is usually conspicuous by absence. none the . fre- quently consist of gross dilatation of one pupil. associated. paresis. but are frankly classified by him. it hemiplegia and cranial nerve palsies of various kinds.. mental symptoms are absent. g. The picture is a radically different one. however.. very remote. with paresis. e. pupil should always suggest parenchymatous syphilis.. the special symp- toms of paresis become more and more apparent. also. These special symptoms consist of palsies.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 311 of cases. involvement men- That tal in long-standing cases of diffuse cerebral weakness —a certain degree of dementia — may their supervene need hardly be pointed out. they are really paretics. e. and the outcome the same. strains of the spirochete. the twitching the facial muscles. If they be followed. faint changing allied and fugitive incoordination of. paresis latter is. but of purely the motor mental symptoms we meet with but few. movement and more it phenomena. i. The pupillary phenomena. It is would seem every that in a small percentage of cases of paresis — as now gum- and then the case in tabes —the special degenerative changes taking place are also accompanied by late though active matous deposits still taking place in vessels and membranes.

in this respect. is Occasionally there a very remarkable simulation of the symptoms of paresis. and this may also be the case with the speech. the signs of mul- tiple cerebrospinal sclerosis assert themselves and the diagnosis reaction. this is time and again the case when the autopsy reveals a marked atheroma . The tremor may not be coarse and widely atactic.312 less cases of paresis. clear. As the disease progresses. so may the mental symptoms come and go. Avith occasionally. the mental symptoms occurring in multiple cerebrospinal sclerosis may be inconstant and shifting. When present the mental symptoms are sometimes hallucinations are present. however. Just as palsies come and go. and may partake. may not be recognized until the autopsy. and. The Wassermann persistently The true nature of the case. That is errors of diagnosis may be made under such circumstances not surprising. MENTAL DISEASES and. those of a dementia. of the same remarkable pecu- liarity of the other symptoms. ARTERIOSCLEROSIS Arteriosclerosis often exists in a marked degree without of there being any mental symptoms moment. too. is becomes negative. MULTIPLE CEREBROSPINAL SCLEROSIS Pronounced mental symptoms in association with multiple cerebrospinal sclerosis are infrequent. it However. they are met this is would appear that is more likely to occur processes. a typical expansive mental state may make appearance. After a time the mental depres- symptoms may recede and a mild dementia with some sion may remain. are no more inas regards the eventual result than are fluenced by treatment ordinary cases of paresis. as just pointed out. when the cortex especially involved in the disease Very curiously. but may resemble that of paresis. At the same its time.

to . agitated. rarely the confusion marked. and. and extremely probable that in such instances the smaller and finer cerebral vessels. or. it In addition. loss of energy. especially involved. The reflexes are never charlittle acteristically changed. may be depressed. The toxic symp- toms present are doubtless to be referred. The symptoms when present are those of ready mental fatigue. Quite frequently. again. may be apathetic is or slightly confused and hallucinararely does he is tory. he can no longer do as much work nor can he do as well as formerly. At times a melancholia simulated and attempts at suicide are known to occur. and suspicious. fers Very often the patient complains of from attacks faintness. the patient complains of in the head. those which supply the cortex. in part at least. in headache or other distressing sensation addition to the lessened capacity for work and impairment of memory. He may even is evolve persecutory ideas. The pupils are nor- mal. Memory becomes somewhat impaired. it may be. sometimes normal. In other cases. present. and spontaneity. the patient may also be easily disturbed and Further. However. or it At other times the patient fearful. symptoms do make it is their appearance in given cases. are also. At times he is somewhat sleepy sleep at night and even somnolent during the day. still more have attacks of stupor. The with cortex its may then suffer because of the serious interference blood supply. less frequently diminished. In some cases the mental symptoms are more pronounced. and even a well-marked insomnia may be of dizziness or sufalso. senility.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 313 of the vessels of the base. irritable. he complains of numbness or of paresthesias of the feet and legs or it may be of the fingers. sometimes a exaggerated. In such cases the latter suggest those of a premature there being a simple and uncomplicated mental loss more or less marked. at others the is much disturbed.

HEMORRHAGE. and the attack may suggest a serous apoplexy rather than one due to hemorrhage or obstruction. and occasionally a tendency to depression and tears are noted. right-sided. apoplectiform crises or. lar lesion of the brain. reveal general mental enfeeblement.314 MENTAL DISEASES tiie associated interstitial changes in kidneys. Quite commonly mental impairment. epileptiform seizures are observed. pneumonia. These symptoms are to arterioirri- and resemble those due A mental feebleness. These may be accompanied or followed by hemiplegias or other palsies. rhage. aphasia in some form present. there if usually a hemiplegia with the common is physical signs. due to the general arterial degeneration present in such brains. in arteriosclerosis. if evident previous to a becomes more pronounced subsequent to such an attack. Such patients may. ordinarily presented is by the Thus. or embolism a cerebral hemor- may occur. generalized in character sclerosis. qerebral apoplexy. thrombosis. followed by the usual train of associated symptoms. in other words. At such times aphasia and other localized phenom- ena may be present. in addition. The latter may be temporary. Now and then. the local lesion may depress the nutrition of the brain as a whole. patients finally die of myocarditis. EMBOLISM. impairment of memory. Not infrequently the dementia becomes quite . tability. nephritis. AND THROMBOSIS When mental symptoms occur in a case of focal vascuthey constitute a group added to those lesion in question. bronchoor. less frequently. or some other complication. possibly also in the liver and other organs. of patients suffering The age The from cerebral arteriosclerosis with mental symptoms ranges from about fifty to sixty years.

even may be present. are general in character. also. however. tires quickly. is a tendency to fabrication. interference with the arterial supply or the venous return. seems to be present. ized loss of mental faculties BRAIN In TUMOR AND BRAIN ABSCESS tumor the symptoms are limited to many cases of brain headache. hemianopsia. the result of the secretion of poisonous substances by the tumor or of its degeneration. astereognosis. At times. somnolent. such as focal epilepsy. is not necessary to point out that dementia should be clearly differentiated from the aphasia or apraxia that is itself. noted. silly. heavy. a mild confusion may supervene. causelessly cheerful. in- normal spontaneity. The patient is apt to be dull. and torpor. vomiting. hallucinations He may be decidedly confused. While aphasia it as pointed out by Marie. childish. Often he is is Sometimes he stupid. drowsy. Sometimes a fictitious memory. In given cases the . marked disturbances are infrequent. loses both the capacity and the initiative for work. states of excitement with hallucinations and On It the whole. may be present. aphasia. Mental impairment may be very evident. an intellectual deficit. delusions. There may be a distinct mental diminution. in some cases an intoxication of the cortex. as in Korsakow's psychosis. such cranial pressure. forgetful.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 315 pronounced. lacks The patient is relaxed. vertigo. depression. The in the larger number. different. obtunded. and the like. and such focal symptoms as may be present when the tumor involves areas of the cortex which yield special reactions. at others. and causes which affect the function of as increase of the intra- doubtless depend upon the cerebrum in its entirety. all cases mental phenomena are added. must not be confused with that generalwhich constitutes a dementia. In about two-thirds of latter. optic neuritis.

when present.316 patient is MENTAL DISEASES much dazed. according to the cortical areas or other portions of the brain involved. to make puns and jests may be present. at first Sometimes. the symptoms paresis. The mental symptoms vary somewhat. the majority of observers are agreed that tumors of the frontal lobe are apt to present greater intellectual is disturbances than growths elsewhere. which the Germans have called "Witzelsucht. also impair- ment of the static function. focal convulsive Tumors attacks of the motor area are manifested by purely focal and other neurologic features. Brain tumors vary greatly as to the degree in which these general symptoms are present. general is mental symptoms are sometimes entirely slow. there obtusion. Thus. Sometimes ataxia a symptom of frontal tumor. or present special features. Quite commonly. even though the growth itself be large. in left frontal tumor. a distinct tendency to form unexpected as- sociations. In addition. He is regards. are factors which also appearance of mental symptoms. denies that these Pfeifer. and may assume automatic or catatonic attitudes. aphasic symptoms as of value. absent when this Again. too. a greater interference with a greater mental memory. as by invasion by the growth." ever. they are It relatively insignificant and of little moment. There are some cases in which they never make their appearance. involvement of the pia in inflammatory processes. or the possible action of toxins upon adjacent portions influence the of the cortex. The . the degree of the involvement of the cortex. is would appear that the rate of development of the tumor at times a factor of moment. either directly or indirectly. sight suggest as in one of my own cases. though this is of course not a mental symptom. symptoms are any more pronounced frontal tumors than with tumors elsewhere. a symptom howwith.

or more tumor excited. mental symptoms however. such well- known phenomena be observed. aphasic symptoms may be present. occur more frequently in tumors of the occipitotem- poral regions. this factor regarded as of doubtful value. However. may be present. in addition such patients are a depressed. Tumors limited to the centrum ovale are not apt to present . save that visual hallucinations — even in my pictures. one of patients had the frequent dreams with vivid whole. the picture may be quite complicated. confusion. patients who are entirely blind —may occur. mental impairment may be noted. may Special mental symptoms can hardly be said to be present. ready fatigue. angry more readily —just is as does the ordinary epileptic- — than when the must be situated elsewhere. Tumors of the parietal lobe may be accompanied by such localizing phenomena as astereognosis. it scenes and On may be said that hallucinations.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 317 general mental it symptoms become of brain tumor may also be present. both of hearing and vision. and frequently very marked general mental probably there is a distinct relation of these facts to the degree of destruction of the great commissural fibers connecting the corresponding areas of the . alexia. lobe. present somnolence. belong to the domain of nervous phenomena rather than of insanity. Tumors of the callosum may loss. there may be distinct psychic losses in the recognition and interpretation of foreign bodies by touch. however. clinical the mental symptoms be pronounced. These symp- toms. general in character if they be large. If the tumor be in the left parietal and contiguous to or pressing upon the temporal lobe. In the left temporal lobe sensory aphasic symptoms. In occipital tumors. little would appear that irritable. as hemianopsia. in addition to the general mental symptoms if of brain tumor. optic aphasia. In such instances.

and does not look upon them as Tumors of the pons and crura are rarely attended by mental changes. Brain abscess may be attended by hebetude and more or marked obtusion. the patient does not is know where he does not understand what said to him. pronounced in character —even is delirium may less complicate the otherwise orderly cHnical picture. and may be so pronounced as to mask the underlying disease and lead it to errors of diagnosis. mild confusion and even hallucinations have been noted. resisting. epilepsy. Sometimes confusion is. the first to conclude that also to break all nervous syphilis is the same (see p. incomplete two hemispheres. which accompany brain tumor are only occasionally can they assist in the diagnosis. is restless. 294) and down the distinguishing landmarks between . It is important to add that every now and then hysteric symptoms are present in brain tumor. however. and asymmetric. may be said that the mental symptoms proper in a sense adventitious . It is important. In conclusion. or hysteria on the TABES Following the discovery of the Treponema paUidum other.— 318 MENTAL DISEASES Diplegia. convulsions are present which may simulate on the one hand. doubtless because of the general intracranial dis- turbances caused by these growths when large. most important. The latter must local- be chiefly based upon the well-known izing classical signs and symptoms. Cerebellar tumors are sometimes attended by general mental symptoms. by Schaudin and the still more convincing discovery by Noguchi tendency was at of the parasite in the brains of paretics. Most frequently and this active mental is phenomena are absent. may- be one of the neurologic findings. to know that mental symptoms. tal Pfeifer regards the men- symptoms of tumors of the callosum as of general value distinctive. only. present. delirious. Occasionally.

. frequently they consist of a narrowing loss a myosis. i. of shooting pains less severe. is Finally. feature. These notably from those met with in paresis. The knee-jerks If at may in taboparesis be much diminis ished or even lost. too. the evolution of the symptoms may be some- what tal slow.— MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS paresis 319 and tabes. the form in which spinal symptoms appear early — which has tended to obscure the subject. of gastric crises. becomes apparent. in taboparesis is rarely so pronounced as to play The writer has never in a case of taboparesis elicited as a beginning symptom a history of difficulty of walking . so that the real nature of the case early Again. with an early impairment or It is of the light reaction. of tabes is the history one of very slow and gradual evolution. further. the same time incoordination little notice- ably absent. incoordination though present a striking role. However. but. of the pupils. of unsteadiness in the mornings while washing the face. to be especially noted.. Most e. of more or delayed sensation in the feet Early. that is in tabes the pupils are equal. as a rule. It has become necessary to emphasize the distinction between the two great parenchymatous or —to employ an old term — parasyphiHtic affections. certain striking differences obtain In the first place. There is a history of difficulty of walking in the dark. the picture of a tabes with or no ataxia may be simulated. The general distinction it between tabes and paresis has long been admitted. i. Men- symptoms also make their appearance. of disturbances of micturition. differ make their appearance. it is far more rapid than in tabes. inequality excessively rare. is the occurrence of taboparesis e. In taboparesis. the ataxia pupillary disturbances and legs. the impairment of the light reaction the same on the two sides. sluggishness and the degree of loss are not more pronounced on one side than on the other. between taboparesis and tabes. becomes a marked Finally.

the changes in the pupils consist for the most part in symmetrical departures from the normal both in size and light reaction. it is Long before the light reaction noted that the pupils are unequal. The reason for this is probably to be sought in the fact that in tabes the myosis and fixation are to be attributed to changes in the cord. Gastric and other crises. the pupil in paresis are peculiar. while in paresis they are directly due to involvement of the brain — of the oculomotor nuclei and of the intracranial of the pupils mechanism upon which the shape and movements depend. ovoid. at most a mild hy- pesthesia. This may be shifting in character. widely diffused but not attended by delay is ob- served." two pupils may one side be In tabes react unequally to light. This irregularity. the pupil may indeed change its shape while under observation and thus justify Finally. Shooting pains also form no. disappears. . or its circumference may be irregular. In short. tabes stands in bold contrast to paresis both in its course and final termination. rare. the the designation "ameboid pupil. At the same time may be noted that one or both pupils are irregular in shape.320 in the MENTAL DISEASES dark or of unsteadiness in the mornings while washing the face. the it may be slightly flattened as by a cord. present at another. the opposite condition to that inequality met with in the great mass of true tabes. it absent at one time. upon the other sluggish or lost. are excessively in the feet Delayed sensation and legs is equally absent. is usually changing and shifting. like the inequality. Disturbances of micturition also form no feature of Further. or a very inconspicuous. the reaction may upon prompt and normal. it may be safely stated. part of the early history. present at times and absent at others. the disturbances of the early history of taboparesis. or be slightly angled. A may pupil may circle be oval. and at no time do they constitute a prominent or striking feature.

lawyers. tabes a disease of a life-time. but of disease of the heart. however.MENTAL DISEASE RELATED TO SOMATIC AFFECTIONS 321 In the great majority of cases of tabes the mental condition is good throughout. i. of an arteriosclerosis. as in paresis. or there may be complete loss of conscious- ness from concussion. Among them we men. of the aorta. Finally. Sometimes other intercurrent mental maladies are observed. business is demand not only tions. of infections of the bladder. that tabetics possess a special vul- nerability. follow pursuits and vocations which entire sanity. of disease of the kidneys. or change altogether to that of an exudative rather than a parasyphilitic affection. The may be dazed. A tabetic who uses alcohol to excess through a delirium tremens or an alcoholic confusion. after a . not of a die. become dizzy. TRAUMA Severe trauma of the head persistent may be followed by transient or patient mental symptoms. Of course a tabetic patient may acquire a mental disease as may any may pass It other person. we should. revise our diagnosis to that of paresis of the ascending form. partially stunned. men of affairs. or other visceral complications. 21 may stagger and perhaps Usually. confused. few years. fall. to a cerebrospinal syphiHs. e. but often very unusual qualificafind physicians. cannot be said. and when tabetics they do not die of a dementia. other things equal. fill Many instances can be cited of tabetics who important positions.. Suicide is in spite of their pains and deplorable condition. When such changes not- withstanding supervene. the patient If the injury has been moderate in may merely turn pale. severity. practically unknown among them. thus they rarely become much depressed. There is nothing in tabes itself— at least this is the uniform result of clinical experi- ence —which leads to mental change.



variable period of quiet, he recovers from the blow and subse-

quently presents no symptoms, save perhaps, for a time, head-

ache and indisposition for exertion.

Frequently no symptoms

falls to



the blow has been severe, the patient

the ground unconscious and presents the physical signs

of shock.



very pale, his extremities cold and moist, and

the pulse very

weak and

Sometimes he



when spoken

to loudly, but usually his answers

are unintelli-

The degree of unconsciousness varies,

of course, with the

violence and the

to the intracranial contents,



also true of the detailed physical signs.

there has been no

extensive extravasation of blood there will be no palsies; sometimes,

however, convulsions are observed.





though they

may be contracted



exists, as, for instance,

from the middle meningeal,


be a dilated pupil on the same side (Hutchinson's
there have been no gross lesions, the patient usually



and becomes conscious within twenty-four hours.


quently he vomits as the reaction comes on.
patient complains of headache and vertigo.
It is probable that

Usually, too, the

blows sufficient to give

rise to


are followed




to the cranial contents,


branes, vessels, and brain substance.

In the case of the


branes and vessels,

we probably have

to deal with contusions

and minute hemorrhages, and,

in the case of the brain sub-








probably also structural in their nature.
ing, therefore, that

not surpris-

mental symptoms


persist after the


has recovered

from the immediate






be more or


confused for days, weeks,

or even

months following a severe concussion.

The confusion




be severe, but usually

it is

mild in type, accompanied by

headache, dizziness, and other distressing sensations.


times the patient has no recollection of the accident or of the
events of some hours or a day or more preceding;
present a retro-anterograde amnesia.
table, depressed,







also irri-

and usually slow

in response.

As time goes

on he usually improves; the improvement, however, may be
very slow.
In other cases permanent mental weakness

a true traumatic dementia.
Instead of the picture of a confusion supervening, a delirium



some days, make



It is


probable that,
involving the




the case, an inflammatory reaction

i. e.,

or possibly the brain substance has

taken place;

that a locaHzed traumatic meningitis or

encephalitis has developed.

important to differentiate confusion and delirium the

result of actual physical injury of the cranial contents,

from the

purely functional nervous disturbances which sometimes follow
the fright or psychic shock of an accident.



do not

from the functional troubles ensuing from accidents in

which the head


no way involved.

As a


they assume
of little

the form of hysteria;

commonly they prove

consequence unless there

present the element of litigation.

True mental

disease, other

than the confusion, delirium, and
of the cranial con-

dementia resulting from destructive injury

never supervenes.

Fright, such as leads to hysteria,

never produces mental disease.

perfectly true that persons

from hysteria


also be depressed
real psychosis

and nosophobic,



have never observed a

develop in such a


Melancholia, for instance,

never caused by trauma;

not even can the value of an exciting cause be ascribed to




my own patients, who had suffered from several



attacks of melancholia, each one of which had necessitated her


to an asylum, suffered during one of her


from a trolley accident

which she received a rather

severe blow on the head.

She developed subsequently not a

melancholia, but a typical hysteria; one, too, which persisted

many months until litigation ceased, when it finally disappeared. What is true of melancholia, it need hardly be added,

also true of the other psychoses.

For instance,


a dementia
it is


discovered in a patient following a trauma,


to infer that the mental affection antedated the accident; or in

any event that a causal

relation does not obtain.

Pregnancy, labor, the puerperal

and the subsequent

suckling of the offspring being basic, racial functions, and in

themselves essentially and intrinsically normal, cannot of themselves cause insanity.

Other facts must of necessity play more

or less important roles in the etiology.



that of a neuropathy, usually inherited; quite

commonly we


a history of mental disease in the ancestry, and at times

even a history of mental breakdowns occurring in the
of a family at the puerperal periods.


It is observed, too, that


who have passed through

attacks of insanity inde-

pendently of pregnancy


again become insane

when a

puerperal period supervenes.
sarily follow;

This does not, however, neces-

in a case of manic-depressive insanity, for a long

time under


observation, the patient passed several times

through pregnancy without incident; indeed, she seemed to be

more nearly normal

at these times than at others.

In the causation of the mental breakdowns there


be, in

addition to a pre-existing neuropathy, also the factor of exhaustion.








overwork or nervous overstrain; that




follow a pregnancy occurring in an already greatly de-

bilitated patient.


powerful, however, than exhaustion

are fright, shock, grief,


especially the

worry and shame

incident to an illegitimate pregnancy.

Finally, into insanity

occurring in the lying-in period there


enter the factor of


insanity which supervenes during pregTiancy
shortly after conception, though



fest itself

much more



comes on much




about the sixth or
after conception has

seventh month.

some women


occurred, an irritabihty, a change in character and disposition,


persists during the first


weeks— sometimes
infrequently this



two or three months.



companied by an unwonted or exaggerated degree


and vomiting; at times,


by unusually marked perversions

or "longings" as to the food which the patient desires.


symptoms sooner




rather early in most cases.

Rarely, however, distinct mental

symptoms make

their appearance.

In such case the patient

becomes depressed, perhaps confused, and gives way to painful
delusions of ill-treatment,

abandonment and,



be, of

being illegitimately pregnant;
their appearance.

sometimes hallucinations make
the mental disturbances of the

As a


early period are rather mild in type; rarely
i. e.,

there excitement;

the clinical picture


usually that of a mild confusion with

painful depression;




actual fact

of illegitimate pregnancy, with its attendant

worry and



given cases, be a powerful contributing factor;


it is

not of

itself sufficient in

an otherwise healthy


to produce insanity;


it is

eventuate in

suicide or other tragedy, but this

not the outcome of disease.



Mental symptoms making

appearance in the early

pregnancy, say before the fourth month, usually

disappear long before pregnancy

terminated, and the labor


lying-in period


in such cases progress in

an entirely

normal manner.


are, of course, exceptions to this rule.


the symptoms appear in the second half or later
of pregnancy, the cUnical picture

similar, save that



more pronounced.


depression and

confusion are more marked, and the hallucinations and delusive ideas are




are of the

same painful


and deal with abuse,


Finally, the

illegitimacy, denial of paternity,

and the


mental symptoms, instead of disappearing, frequently persist

pregnancy has terminated, at

least until the

the whole,

has been completed and sometimes longer.


should be added that insanity of pregnancy
it is

is rare.



not improbable that the patient, for some as yet

unexplained reason, suffers from a toxic metabolism.

almost uniformly good.


infrequently the insanity

met with during pregnancy

spoken of as a melancholia, a term which

obviously in-



patient in the

depressive phase of a manic-

depressive cycle may, of course, pass through a pregnancy,
but, as already pointed out, a causal relation does not obtain.
Similarly a pregnancy


occur in the course of a dementia

which case hebephrenic, catatonic, or paranoid
appearance during the pregnancy

phenomena may make
or subsequently.

would be obviously incorrect to attribute

the insanity in such a case to the pregnancy, the puerperium,
or the subsequent lactation.


the other hand, pregnancy

seems at times to hasten or to favor the development of a dementia prsecox, as

though a disturbed metabolism or exhaustion of

the sex glands played a

(See also p. 131.)

Obviously, beits

cause of the unfavorable prognosis of dementia prsecox,

proper recognition under these circumstances


of the


Every now and then mental symptoms make
during parturition.



The shock and excitement

of labor

by a
It is

in a neuropathic individual be accompanied or followed


Usually such a delirium
or convulsive


of brief duration.

when uremic


are also present

that the


of consequence.

Ordinarily the delirium


of little significance.


it is




insanity that supervenes during the lying-in period

alike the

most frequent and the most important.


in the

insanity of pregnancy, there

a previously existing neurop-



elements are, however, very important factors.

After delivery there

a marked change in metabolism;


enlarged uterus undergoes rapid involution and absorption,
while the


glands become engorged and active.


not improbable that, owing to an abnormal metabolism, a

defective reaction of the glands of internal secretion, an imperfect oxidation, or other cause, large


of toxic substances

find their


into the circulation.

Rarely does infection play

a role; time and again cases are observed in which neither the
general nor the local signs of infection are present; that

neither rise of temperature nor the physical evidences of infection of the genital tract.

Exhaustion, shock, and fright also

play a varying


Puerperal insanity
it is

often spoken of as puerperal mania; in

not a mania, but a delirium.

more frequent

after the birth of the first child;

occurs somewhat

more frequently

in persons


begin bearing children late;


attacks not infrequently recur with each succeeding

pregnancy, though this

not invariable.




preceded, as a rule,


certain suggestive



patient ceases to do


she becomes anxious,

nervous, irritable, and depressed;

at times she manifests an

unnatural aversion for the child or for the husband.
her appetite, the skin




and the bowels constipated.

She becomes


and great weakness makes
lochia usually


The milk and

become diminished

or suppressed, though in


cases they are not, at first at

markedly influenced.

Finally, after a variable period,





Sometimes prodromata are

not observed, and in such case the mental symptoms


appearance suddenly.

Usually the onset occurs within
as early as the fifth or
after the



two weeks, quiet frequently

sixth day, or

may be not until the ninth or tenth day;
of the onset the patient

patient has begun to leave her bed.

At the time

becomes obtunded and




and delusions make

their appearance.

Soon an active delirium supervenes which

reaches a high degree of intensity; the patient becomes greatly



Hallucinations of vision are numerous and

vivid; this

also true of hallucinations of smell

those of hear-

ing seem to be less prominent.

The delusions are imsystematized, The
picture presented does not
(See p. 46.)

changing, and fragmentary.

from that seen

in ordinary delirium.

As a

puerperal delirium persists with great activity for several

days or possibly a week or two, after which the intensity of the



and the symptoms

persist as


active confusion (see p. 50) for several months; four


not unusual, and


longer periods are frequent.

times the excitement

moderate throughout and convales-

cence begins after six or eight weeks.

Such a favorable course

however, unusual.

After a time the excitement diminishes,

the confusion becomes less pronounced, the patient begins
to recognize her surroundings, and, lastly

—and most important


to realize that she has been

takes her food


and convalescence becomes established.

The symp-

toms and course of an attack vary greatly in
prognosis of puerperal insanity
ever, exhaustion

different cases.


almost uniformly good.


sometimes becomes extreme, and second and

third attacks are less promising than the

Visceral compli-

cations are infrequent.

Every now and then,

in persons of

a neuropathic history or

make-up, insanity makes

appearance during the period of

Usually, several

months elapse before the symp-

toms are observed.

As a

rule the patient passes through a

prodromal period of exhaustion, and, toward the third or subsequent months of nursing, the patient becomes

much depressed,

confused, and hallucinatory; in other words, the patient passes

through an attack of confusion with painful hallucinations and

Quite commonly the excitement


moderate in

degree, though


be subject to marked exacerbations in

which the patient




delusions betray

nothing characteristic; they are fragmentary, changeable and

always painful and distressing.

The confusion does not


from that met with in the other exhausted

(See p. 49.)

Sometimes there
to the child.


fear of

impending death sometimes aversion

That the patient should be promptly separated

from the child need hardly be pointed out.
the insanity of lactation
four, or longer.

The duration


always a number of months


Its pathology, also,

clearly that of a toxic





studied the clinical forms in which mental disease


and the

relation of these forms to the somatic


next in order to approach the subject from

the standpoint of age.

In so doing,


will pass

over ground

much of which



but some of which


Age may be conveniently divided
(1) (2) (3)

into six periods:

Infancy, the period from birth to puberty;

Adolescence, the period from puberty to adult age;

Early Adult Age;


Mature Adult Age;
Middle Age; and
Old Age.


Such a

though largely arbitrary,


clinically useful.

When we

take up the period of infancy,


find at once that

the subject resolves

into a consideration,

of insanity

in children and, second, of mental deficiencies the result of

arrested development or gross pathologic conditions.

Insanity in childhood

excessively rare.


must be

i. e.,

from idiocy and imbecility.



remember, consists in a change in the quality of mind;
a change in the


of thinking, acting,

and feeUng, while
It is a

and imbecility are

states of quantitative defect.

remarkable fact that, as regards mental diseases, the influence
of heredity does not


itself felt in

a decided



very rarely. excessively rare. dementia prsecox appears before puberty. childhood is be added that suicide in also very infrequent. fess to it may make premature profession of or may con- imaginary sins. or other symptoms strongly suggestive neurasthenic-neuropathic^the psychasthenic Part I. manifested clearly the depressive and hallucinatory phase at eight years of age. in- stead of presenting the purely objective and aggressive attitude of the normal mind in childhood. sometimes present suggestive premonitory Thus. However. mercy. may manifest a veritable religious exis altation. of the habit spasms. excite Sometimes the act pity. may be morbidly conscienreligion. Sometimes the child develops tics. to avoid the or. and were attributed to men who were Equally rare is trying to the patient. to es- cape cruelty. In one of my own cases the patient.). children signs. or is originally a pretence to is sympathy. may be. As a rule. those of hear- ing were in part described as pistol-shots. are present in children they are. At times the manic-depressive make-up distinctly foreshadowed. it consequences of some act of disobedience. It should however. is the suicide the result of ideas of self-accusation or of the unpardonable sin. as when such symptoms seen (loc.) Less frequently it manifests a well- defined special fear. tious. cit. Typical melancholia and typical mania are. When children commit suicide they do so usually to avoid punishment.MENTAL DISEASES AS RELATED TO AGE after puberty or until adult life is 331 reached. a well-defined indecision or aboulia. but in which the pretence if carried too far. fear. self-distrust. ever. — disorders. unreasonable may It manifest excessive shyness. little tricks of movement. the child It may be self-con- scious and introspective. (See Chapter VI. Rarely. the hallucinations were many of them kill very vivid . the condition which Sander has described as . a boy. Again. we have generalized in type.

and it is not impossible that disease more especially hyperpinealism. and stupor. In addition to the mental disturbances above noted. As is in paranoia of the adult. in whom a neuropathic heredity usually quite pronounced. He Often morbidly sensitive and easily irritated or depressed. a rapidly deteriorating hebephrenia. manifest themselves. possibly. supervenes and a dementia terminates that the picture. more or pronounced. less cheerful than other children. The unusual sexual precocity points strongly to disease of the pineal gland. children of course suffer from the mental affections of the first group in the delirium. Soon he believes that he he is is being neglected by his parents. the patient may believe that he born of a great family. he suffers from dreams which seem to prolong themselves into the waking period. that not being treated as well it is as his brothers and sisters." paranoia originaria. confusion. presents an introspective attitude of mind. In time mental weakness. At a is very- early age the child. The relation between pineal excess and sexual precocity. of the internal secretions. at times persecutory and at times expansive. Delirium. as Kraepelin thinks. that he has been substituted in lie the cradle. The symptoms suggest we have here to do with a very early form of dementia praecox. He is is less happy. —that he by is precocious sex- This precocity ideas. makes such a view highly probable. plays here a role. a knowledge of which we owe especially to von Frankl-Hochwart. often the course less very irregular. At the same time noted —and this is a striking feature of his case ually. that great riches and a great future before him.— 332 "originare MENTAL DISEASES Verriicktheit. At the same time delusions. The of progress of the affection is often interrupted is by intervals improvement. as met with . is characterized also erotic dreams and erotic and may be accompanied by premature physical sexual development.

g. sharp distinction cannot be drawn between idiots and imbeciles. (See p. and yet are useful as accentuating However.. children. the entire group is spoken of as idiots. as already pointed out. the common mental disturbance. middle-grade. too. then too. Such a classification enables teachers to group together cases training. commonly. not until puberty law. 21). is also true of stupor..) IDIOCY AND IMBECILITY Idiocy and imbecility are. typhoid fever. is The idiot is a child in whom this deficiency gross and i. is reached or until adolescence will is advanced. 270. two or three years. may succeed This a delirium. more or less persistent. a the essential features of the two conditions. (See p. Occasionally a protracted ex- citement with delirium follows shock or fright. is a few months. but the latter is it is quite rare. defines the idiot as a child born without mind and the imbecile as an adult with the mind of a child. The imbecile one in whom the deficiency does not become apparent until much later. the victims of inherited syphilis. e. 35. and in practice we are in the habit of grouping them together quite are under the general caption of feeble-minded children. states of mental deficiency. is evident at birth or within a short period after birth. are excessive. requiring similar kinds of management and A more . The we remember (see p. Both definitions. and high-grade idiots.) This has already been suffi- ciently considered. may pre- sent a dementia or may suffer from j uvenile paresis. not until a number of years have passed — it may well be. or may make its appearance during the postfebrile period of one of the exanthemata. Confusion. Finally. who classified in accordance with the degree of their mental deficiency into low-grade. as already pointed out. though after met with somewhat more frequently.MENTAL DISEASES AS RELATED TO AGE febrile periods of the 333 is exanthemata and other infections. e.

arrests of 2. MORPHOLOGIC The idiots IDIOCIES with morphologic abnormalities are those in whom the organism has failed to unfold or develop either in the normal manner or to the normal degree. 4. one which enables the its physician to at once place a given case in relations. g. the lobes of the ears absent or confluent with the cheek. to present fissures an unusual paucity or simplicity of or anomalies of fissures and convolutions. the idiot with morphologic stigmata analo- gous to a bud. and convolutions may be observed suggesting conditions keys. is proper nosologic for and which the writer has employed many years. trunk. features. e. all expressive of arrest or deviation. the forehead unusually low and narrow. sunken in the bridge.334 MENTAL DISEASES classification. owing to some inherent defect in growth . which. crushed or flaring. development and deviations. Thus. i. the latter may be found to be abnormally small (microcephalic). the palate deep.. irregular and narrow. 3. or the nares divergent. Idiocy presenting general morphologic changes. expanded. the dentition defective or anomalous. the head may be unusually small. Idiocy presenting gross pathologic lesions of the nervous e. met with normally in the apes and monis In short. the following: 1. and limbs. flattened. They present. other things equal. as may also itself of the limbs and the trunk. with per- haps an exaggerated Darwinian tubercle. the hemiplegic and diplegic idiots.. Cretinism. the pinna irregular. comprehensive however. Similarly the nose may be altered in shape. anomalies of the head. Amaurotic family idiocy. the opportunity presents examining the brain. The digits may show irregularities of length If and development. system.

is The Chinese-like appearance of these children often very striking. the cases are often spoken of as birth-palsies. the Other racial forms. occur with considerable frequency. an unusual degree of brachy- cephaly. among has other parts. withered or is deflected from normal pathway of development. There is always present a lesion of one or both hemispheres. often there is also a certain obliquity of the palpe- bral fissures. such as I Malay and Red Indian types. In cases which reach autopsy extensive sides. a . Quite commonly the lesion its origin in difficult and delayed labor. Among the most interesting forms in the group of morphologic idiots are those in whom the outward appearance simulates that of some race of patient springs. PATHOLOGIC IDIOCIES Idiots with gross pathologic changes. the motor area. indeed. mankind other than that from which the of these is The most frequent In this there is that known as Mongolian idiocy.MENTAL DISEASES AS RELATED TO AGE 335 of dis- —an its agenesis — or. The hemorrhage appears to arise from the veins. such as hemiplegia and diplegia. . and even at times an unusual pigmentation of the skin. If and posteriorly the child survives. myself seen clearly marked instances of these. They are frequently due to prolonged compression or constriction of the head. involving. In other cases there is a distinct negroid shape of the skull and of the features. however. in there is which a more or less extensive extravasation of blood over one or both hemispheres. have been described have not. near or at their entrance into the superior longitudinal sinus. it hemorrhage is found over the vertex. together with an unusual lateral expansion and height of forehead . on one or both may extend downward over the lateral aspect and anteriorly to a variable degree. owing to the retarding influence is ease inherited or congenital.

less is the term applied to myxedema it is occurring in Like myxedema in the adult. However. 245. fever. A similar arrest takes place Occasionally marked loss of substance occurs. and vascular lesions. pathologic conditions occurring in such as ependymitis. sclerosis. it has been measles. known to occur during or following scarlet fever. Some of these cases are classified under Little's disease. the results of infections. tumor.) The . Thus. or other gross such as hydrocephalus.336 MENTAL DISEASES hemiplegia or diplegia follows. but occurs subsequently and then its usually has origin in some infection. intra-uterine life. volvement Finall}'^. due to a more or thyroid gland marked hypothyroidism. a so-called porencephalus. seems to be the causal factor. CRETINISM Cretinism children. diphtheria. due to failure of the upper motor neurones and tracts to develop. Sometimes there is atrophy and the sclerosis may be confined to a few convolutions may be widely diffused. typhoid likewise to deal with We have here damage to brain tissue secondary to inblood-vessels. The symptoms in a given case will or will not include those of hemiplegia in accordance with involvement or absence of in- volvement of the motor area and pathways. Occasionally an idiocy due to gross pathologic change finds its explanation at the autopsy in an extensive atrophy. an abiogenesis. whooping cough. or Much less frequently the hemiplegia or diplegia does not arise at the time of birth. of membranes and more rarely. seem to be the more common causes. In some cases simple prenatal arrest. which extends from the general brain surface downward to a variable depth. together with the formation of a cyst. the cerebral palsy is prenatal in its origin. in the adjacent areas. (See p. brain lesion. meningitis.

with the perception of cutaneous impressions. the limbs are crooked. the may not be noted for several years. the eyelids are puffy. As a rule. smell. thyroid disease ever. However. The rounded and swollen. We note latter is is at once that the stature much dwarfed and and that the skin everywhere presents a diffuse jelly-like infiltration. In others. The physical signs presented by the is cretin are very striking. taste. it is difficult Because of the mental condition.MENTAL DISEASES AS RELATED TO AGE 337 i. feet. The face most marked in the face. the child apparently normal at birth and evidences of usually. first five how- symptoms appear within the years. the abdomen less and often pendulous. to judge of the special senses. the movegait ments slow and the the patient has awkward. much decayed. The muscles are soft and little strength. is and hearing appear to be much below though to a less extent. the latter either never or only imperfectly established. The hands and above the feet are much flattened. least of all. consequently the bones of the limbs tend to increase in width. Often the tongue enlarged and protruding. hands. the shafts of the long to grow because of a tendency of the diaphyses and the epiphyses to unite. the teeth are distorted. may there fail is to develop or in may undergo atrophy before birth. the bridge of the nose itself is lips frequently sunken and is the nose broad and flat. normal. vision seems to suffer 22 . is The ears are apt to be large and The skull markedly brachycephalic occipital fail because of a premature . excep- tionally only are they delayed as late as puberty or adolescence. this also the case. is There are full diffuse swellings clavicles. is Should the child survive until puberty is reached. e. union of the basibones and basisphenoid similarly. many is cases a congenital thyroid deficiency. There is a more or marked lordosis of the lumbar spine.. the cheeks and distended.

the hair coarse and thick. to hold up its head. is indifferent. are incapable of Many of the patients cannot learn to training. felt. talk. able to sit Soon it is no longer up. Sachs. may. Their mental processes are very slow. AMAUROTIC FAMILY IDIOCY Amaurotic family idiocy is a remarkable affection. ceases to look about. begins to reveal striking changes. almost exclusively. The mental condition is essentially one of marked deficiency. if annoyed. is noted. give way to outbursts of anger. it would seem. it is very scanty. Usually no thyroid gland can be on the other hand. they are stupid. Only a few are capable any employment. if so. It does and no longer grasps at objects. now is. while usually quiet. the latter are so symptoms as to marked leave no doubt as to the diagnosis. Its weakness becomes progressively worse. Many of of those who learn to talk usually sit about unoccupied without interest and without emotion. present the above in varying degrees. for a It occurs knowledge of which we are indebted to B. often sleep a great deal. becomes weak and relaxed. in in children of Polish-Jewish commonly a number of children in the same The year. The temperature as a slightly subnormal. but. but in the first more frequently between the fourth It to the tenth month. parentage. while the pulse and respiration are distinctly slow. as a rule. and later to swallow properh\ Not infrequently wasting and contractures make their appear- . cannot stand or walk unassisted. and family.338 MENTAL DISEASES skin is The a rule. patient presents nothing unusual at birth. Different patients. and are filthy in their habits. of course. is As no hair found upon the body. dry and wrinkled. cries a great deal. and then an enlargement rule. not see as before. and.

Sometimes a Babinski reflex of the great toe. The affection lasts for several years. picture. or. The children deteriorate mentally. lose interest. movements of the tongue and lips. in the the. become indifferent. and epileptic seizures may be added. save perhaps a few articulate expressions. spasticity. tensive atrophic degeneration of cefls not only in the cortex but in the brain and cord generally. drooling. Blindness also sets which finally becomes complete. probably the other special senses creasing mental loss. they are normal or absent. lose their speech. is noted and at others a persistent extension An lutea. Tuberculosis findings. third year of complete The microscopical and findings reveal exfibers. rolling and restlessness of the eyeball. while infant form a familial disease. lose their memory. Nys- tagmus. in. The microscopic as in the infant form. a red spot surrounded by a dull white area. though much nile less profound. appears to terminate the picture. at Marasmus life. less frequently. The ophthalmoscope reveals Paralyses.MENTAL DISEASES AS RELATED TO AGE ance in the muscles. it is However. examination of the eye-grounds reveals optic atrophy to- gether with remarkable appearances in the region of the macula namely. it is not especially confined to the Jewish race. optic atrophy. consist of similar degenerative changes. Spieimeyer and Vogt have described a somewhat similar degenerative affection occurring in children at from six to ten years. become filthy. Vogt speaks of this form as a juvelike the form of amaurotic family idiocy. and finally death. Hearing likewise becomes impaired and also. There is a rapid and in- which is after a time complete. Among the factors which play a part in the etiology of feeble- . also automatic irregular or rhythmic may be present. 339 in- The tendon reflexes are commonly creased. second most.

plegias. cortical agenesis or arrest not di- uncommon. Among those occurring subsequent to birth we and have. of the digestive tract. on the whole. especially i. is also a serious menace although it should be added that in healthy stocks consanguinity in the human species seems to be is no more factor injurious than in animals. Exhausting diseases affecting the mother at the time of pregnancy have an especially baneful influence. Among the common infec- causes of death are tuberculosis.. would appear. of feeble-minded children is. save . die in the second decade. and hemorrhage of the cerebral vessels.340 MENTAL DISEASES it mindedness in general. as already stated. The duration is of life of feeble-minded children. as well as various affections of the and nervous system. epilepsy. one of simple hygienic management. thrombosis. a greatly lessened resistance to infection. of the kidneys. in the etiology of the morphologic cases. Among the the congenital hemiplegias and we have dystocia and cognate factors already considered. we have various diseases and pathologic states in the ancestry. Little can be expected in any case from the internal administration of remedies. and. and other tious diseases. and other nervous affections. e. such as embolism. a very small number and almost none survive to a later period. and by far the larger number Barr's statistics show that a few to the fourth. Among these should be mentioned tuberculosis. survive to the third decade. diseases of the heart. insanity. as a group. the various infectious diseases traumata. Consanguinity in neuropathic stocks to the offspring. syphilis. fortunately not great. They have. Premature birth another is occasionally noted. alcoholism. pneumonia. and meningitis. The treatment of necessity. those with simple de- velopmental arrest.

skull which the bones of the surgical seem to have united as prematurely. that of it is special training and many cases of advantage to precede the institution of a special plan of education the child to a series of mental tests. cases. in which inherited syphilis is clearly the etiologic factor. Gradually the amount should be increased this should until a full dose is reached. likewise fail of result. again. 341 is Here desiccated thyroid often of great value. the doses of the thyroid should be quite small. especially this the case the is treatment has been delayed until puberty or adolescence reached. the child begins to grow. in or no consequence. but be done with care and judgment. by submitting tests that Of the various have been devised those of Binet is and Simon appear to be the most useful. Care should be exercised. whom the affection has existed for a is less number is improvement decided.— MENTAL DISEASES AS RELATED TO AGE in the single instance of cretinism. When the treatment initial is begun. sufficiently varied in type to explore . the iodids little and mercurials unIn other fortunately yield results of cases. the child should be put to bed. especially freely. If the treatment be instituted early. the torpor vanishes. in long-standing not to use the thyroid too In cases of feeble-mindedness. say one-fourth of a grain three times daily. procedures — such craniectomy intended to give the brain a greater opportunity of growth and expansion. "Their object to provide a quick means for the psychologic diagnosis of the grade of intelligence of a back- ward or abnormal child by means of thirty tests of a simple but precise character. The method In of treatment usually resorted to in feebleis minded children generally instruction. and the child becomes alert and intellectually active. the myxedematous infiltration disappears. is The change in patients of years the if which ensues in in early cases often remarkable.

meager. to teach the child to stand.. e. is and exercises By appropriate methods speech see. Sometimes. to become cleanly. ability rather The tests are designed to measure native than erudition or scholastic attainment. every 1 now and then unusually pre- Whipple. quite frequently the mental one of very irregular and unequal development. and that recovery from fatigue is less than in the normal child. encouraged and improved. on the whole. to insure the goodwill and active co-operation of the child. much is accomplished. arrest of the idiot mind is usually general in character.^ They require much time It is is and patience. ." (Whipple. and to avoid restraint or timidity.. Such work naturally falls lot of the trained educator. the idiot child is Thus. the various faculties of the mind reveal a proportionate lack of development. to walk. the frequent death of the patients in the sets a sad limit to second decade of life our best efforts. improve the coordination. and should be appHed by persons who have famiUarized themselves with the method by practice. e. also important to bear in mind that the defective child very rapid readily fatigued. the eyes are trained to the ears to the to hear. adaptability). if filthy. They are to be admin- istered individually. in the train- such as teaching the child. Very commonly general principles are followed ing.342 all MENTAL DISEASES the important phases of intellectual capacity (with special reference to judgment— good sense. the hands to feel. however. i. and of such a kind as to permit an intelligent investigator to child's form an independent estimate of the mental equipment. to give the evacuation of the bladder and bowels a definite and finally normal attention. state is However. The i. initiative. the results are Finally. in individual cases. " Manual of Mental and Physical Tests/' 1910. Drills and to perform other movements properly. with suitable precautions.

the various forms dementia prsecox. . ADOLESCENCE We of have already fully considered the principal mental dis- turbances of the adolescent period. it they may be able to repeat long citations of the meaning of which. hand." Thus. life we have seen. they and often long quotations in foreign lan- guages. in a sense. with the infections. on the other The neurasthenic-neuropathic group are. they may reveal an abnormal memory. of course. or. This is true also of the feeble-minded child in whom the faculties have suffered a general arrest second decade . however. however. EARLY ADULT AGE The first is third decade of is pre-eminently the period for the appearance of mania and melancholia. as we have seen. as —the psychasthenias —however. confusion and stupor associated Pure manic-depressive states. the third decade the period of fatal termination. Among the latter are the so-called learned idiots. quite frequently. namely. "idiots savants. will acquire phrases may be. meet with the delirium. neither originality finally. merely automatic reproduction. Delirium. not infrequent. idiot survives until adult life is the reached. are rare. or perhaps he has a remark- able aptitude for music. There is. At this period of life we may also. Sometimes a remarkable memory the idiot is for dates is revealed or a lightning calculator. confusion and stupor from infection and toxicity are. they have no comprehension. of the meaning of which they are likewise ignorant. Dementia prsecox also met with at this time is . if nor invention.MENTAL DISEASES AS RELATED TO AGE 343 cocious in certain directions or reveals unusual aptitudes and powers. the approach toward the end of the is for the idiot usually a period of degeneration. his unusual powers become less pronounced or even disappear. of course.

Again.) at times. extremely probable. met with with con- MATURE ADULT AGE Mature adult age —twenty-five to of forty-five — is a period in which are met recurrent attacks mania and melancholia course. (See The other mental disorders present in the earlier life. by a marked sexual Active eroticism re- crudescence. . and also true. of the disorders dependent upon the infections. of paresis. than that of the melancholia of early life. disorders are somewhat less frequent than in early MIDDLE AGE The form of mental disease met with most frequently at the life is middle period of the melancholia of middle age. by open breaches of conduct. by open advances. That this is but a part of the is. periods of adult paranoia and paresis.. intoxications. or marriage with men very much younger than the patient. and at times is accompanied. The neurasthenic-neuropathic disorders are also siderable frequency. is Paranoia may have its inception at this age. The neurasthenic-neuropathic life. by elopements and. affairs. may manifest itself in various love ways. p. 103.344 also MENTAL DISEASES met this with. delusions of Paranoid mental states in which persecution dominate the clinical picture are by no means uncommon. intrigues. though infrequent. of It should be membered that the prognosis middle age melancholia is less favorable. the so- called melancholia of involution. are also met with here. both as regards duration and as regards recovery. g. as and also paranoia and paresis. letters. is not unknown at this period. e. Hj'^pomania occurs somewhat more frequently than mania. and cognate causes. mania. scandals. as well. general syndrome of ordinary manic-depressive insanity as re- we have pointed out. especially in women. though less frequently.

of a lessening in the general range of activities. visceral disease perhaps a little more frequent than OLD AGE Old age is essentially a period of involution of nutrition. but this is limited in degree. I. all of is them expressive of senescence.) 345 The neurasthenic- neuropathic disorders are infrequent. majority of mankind entirely normal and in no sense pathologic. them first are gradually The impairment forgetfulness.) We wall not to say. ideas. there are phenomena of of a simple senile dementia. and especially it when associated with qualitative changes. its The heart no former energy^ longer has the power to drive the blood with while the vessels present walls no longer soft and yielding. commonly. —When and excessive reduction its without qualitative changes makes present the stitute appearance. and. Noticeably this the case with the heart and blood-vessels. those due to in earlier life. but now rigid and with a narrowed lumen. (They have already been considered in Part here rehearse them. that memory. and to properly of the ability to do work. That the brain must inevitably betray the evidences very evident. however. It is it is only when this reduction is excessive.MENTAL DISEASES AS RELATED TO AGE (See p. suffice it Chapter VII. 167. There is a quantitative reduction. later memory at reveals itself by mere by . in the vast of a lessened nutrition is The changes of function that ensue are. judgment. that becomes pathologic. simple Senile Dementia. so that the individual continues to discharge his functions normally to the end of life. to take in coordinate new lost. also Part III. The organism begins to reveal gradual and increasing changes in its structure. of diminished power for the sustained expenditure of energy. infections Disturbances due to the and intoxications are less common. they con- those a simple primary dementia. Chapter I.

vaguely systemNaturally. frequently it is is mild and passive. and in such cases the pict- ure of senile mental loss sion. and. to be added* the phenomena of diminished nutrition there may those of toxicity and exhaustion. other symptoms indicative of qualitative mental changes are added. times — incorrectly. passive or active. both hallucinations and delusions are painful in character. Senile Confusion. Occasionally the patient refers his hallucinations to the persons about him. atized. In other words. friends or relatives are inimical to him. indeed. indeed.346 failure MENTAL DISEASES to remember recent of events. is usually unable to attend to his own wants and needs personal care. begins to think that his neighbors. is complicated by that of confu- There may be present hallucinations and unsystemausually tized delusions. may be much disturbed and excited. may course —spoken of as senile Again. patient childish. the period middle life life is even the memories of early and youth are The The other mental faculties share in the general deterioration until a more or less marked dementia is is finally established. —Senile dementia does not always prein sent itself in the simple and uncomplicated form. he may acquire a distinctly paranoid or perse- cutory attitude. if His delusions are. lost. give way now and then to During such episodes the patient is episodes of delirium. and may. perhaps the larger number of cases. perhaps. also. a patient in noted. however. has been at another time be relatively clear. only the underlying symptoms of the quantitative the . and such a case of somemania. Gradually the defects invaded. Thus. the confusion varies greatly it at all. in degree. to kill him. grow deeper. at other times active. presenting then loss. whom confusion. are trying in some way to harm or injure him or. finally.

susforgetful. though picious. a lapse in an otherwise assiduous devotion may give rise to ideas of gross indifference and neglect. is merely scheming to get his (the patient's) trifling money. Occasionally. acquire the notion that the son or daughter who is so devoted or. marriage suffers — is the very one most from the caprice and injustice of the testator. beliefs his actual intentions — upon delusive —may not become known to de- until after his death. The patient may. Very frequently. on the one hand. Under these circumstances the care and ministraand tions of relatives may be greatly misinterpreted. That such a patient not infrequently becomes a prey . tentions based and childish. Sometimes the son or the daughter who has made the greatest sacrifices who who has given up career. Quite commonly the suspicions and delusions of the latter are concealed during his lifetime. on the other hand. success. he com- municates them in secrecy to a visitor or to a child or other relative whom is he sees only infrequently." — Every now and then friends ginning senile dementia become morbidly sensitive and suspicious. and \\ill is not surprising that under these circumstances a is is sometimes made in which gross injustice or other relative done to the child who is the most deserving. irritable. however. noted that he is is pecuUar. Sometimes halluci- nations of taste and smell are present and the patient believes that he being poisoned. and even filthy. and that he unin- reasonable. 347 Doubtless the confusion has defective its origin in defective metabohsm and ehmination.— MENTAL DISEASES AS RELATED TO AGE dementia. it Refusal of food or the maimer of accepting may reveal the delusion. patients with be- Senile "Paranoia. or the latter becoming insistent the patient may it openly accuse those is about him. untidy. With time such ideas it may acquire all the force of fixed delusions.

Not quently the intrigue succeeds the more readily when. delu- sions may manifest themselves. Among these are expansive of the patient. Sexual recrudescence in old age is of course always pathologic. and delusions and influences the latter in the making of a will to his or her advantage and to the disadvantage who may have as great or even greater claim upon the Not infrequently it is a servant. the patient is also a sufferer is from prostatic disease. During the time that the patient is in this condition. and to woman who is the object of his affection. At times the above picture is com- pUcated by confusion. prejudices. and that subsequent contests a not unfamiliar story.348 signing persons relative is MENTAL DISEASES also true. to his children. but under its influence an old man may fall in love. or there may be involve- . That under such circumstances in families. taking advantage between nurse and patient. testator's bounty. Sometimes it is a child or other who ensconces himself behind the suspicions. of the patient. delusions as to the physical health and vigor and also persecutory delusions as to ill-treatment and abuse by children or other relatives who very naturally oppose his serious marrying. whom he may whom he may bequeath the bulk of his estate. as frequently the case in aged men. that trouble and imhappiness occurs wills are is improper and unjust arise in the courts made. attendant. the bladder frequently becomes in- fected from repeated catheterization. Sometimes a clever and of the intimacy existing designing woman. leaving little or nothing. perhaps the chief beneficiary. Under these circumstances there sometimes a remarkable recrudescence of sexual thoughts and feelings. and may the fall hopelessly and helplessly under the influence of marry. of others or nurse who thus intrenches himself. so plays upon the mental weakness of the latter as to bring about the making of a will in which infreis she is a beneficiary. it may be.

is sometimes cited an aged as proof of his sanity. becomes incon- tinent. checkers. He understands no directions. and marriage. exhibit automatic movements. or defecated Occasionally cases of senile dementia with prostatic disease manifest eroticism and sexual recrudescence in other ways than by love affairs. cannot ings. to practise exhibitionism. or even to attempt rape. becomes garrulous. has urinated on the into his clothes. mumbles to himself. man may. Sometimes a man previously respectable and of irreproachable character begins to consort with lewd women. laugh. persecutory. under these circumstances. may sing. — Kraepelin is has given this name to a group of cases described by Alzheimer. special is pronounced. The patient becomes con- make himself understood. or other games. or ex- pansive delusions have made their appearance. The dementia is progressive over Loss of memory. As a matter of fact. after erotic. Usually the mental less examination reveals senile stigmata more or Alzheimer's Disease. and hallucinatory. continues for a long time to perform acts that he has been in the habit of per- forming many times and for many years. the same time. lack of clearness are increasingly evident. just such a patient At may be unaware that he floor. to sign and endorse may subscribe his name to other papers. play cards. continue checks. has broken wind.MENTAL DISEASES AS RELATED TO AGE ment of the kidneys. proposals. and thus present a superficial appearance of mental integrity. 349 already and the patient becomes. poverty of thought. interprets no gestures. several years. in his weakened state. gives away his belong- He is restless. to toy with children. also toxic The fact that the patient. give accus- tomed directions. The affection characterized by a slowly developing but very marked mental accompanied by symptoms suggest- deterioration and which ing an organic brain disease. . fused.

Among gait. especially in the legs. The clinical picture suggests that in Alzheimer's disease we have to deal with an especially severe form of senile dementia. of himself in anj' his hands. points to a precocious senile dementia. He may begin with a few phrases or sentences coherently. repeats words and syllables. he becomes quite mute. Finally. before years of age. spasticity of muscles. reveals changes in keeping with those of a grave The autopsy senile dementia. of fibrillar The places by bundles The latter stahi and are probably the remains of former cell bodies. with a colorless material probably the result of nerve substance destruction. However. the physical signs are marked general weakness. especially around the necrotic foci. and usually ends in a meaningless gabble. The fifty fact that it may begin relatively early. uncertain Focal brain symptoms are not present unless it be the aphasic and apractic disturbances. while extensive de- struction of the cortical cells of the latter are taken deeplj^ is everywhere noted. but possibly is a special pathological process independent of age at work. a shuffling. sclerosis is present. The gUa shows extensive prohferation. His speech greatly disturbed. The latter are filled. He His becomes unable to feed himself or to take care way. the necrotic foci seen in ordinary senile dementia are here very numerous. . for instance. but soon halts. as in senile dementia. at most uttering oc- casional words or senseless syllables under excitement.350 recognizes no objects MENTAL DISEASES and is is unable to carry out any orderly procedure. At times arterio- After a number of years the patients finally succumb to intercurrent disease. He places is in his mouth whatever is put in dementia profound. The pupillary reactions appear to be diminished. Several of Kraepelin's patients suf- fered from isolated epileptiform seizures.

the same admixture cholia of middle of hypochondriacal ideas. it is very prolonged. In its symptomatology. unmistakable signs of actual mental loss should be carefully sought for.MENTAL DISEASES AS RELATED TO AGE Senile Melancholia and Senile Mania. may become The dif- chronic or may terminate in dementia. periods of It is. mania quite rare. now and then a senile melancholia makes a good recovery. . Their presence in a degree strongly favors the diagnosis of senile dementia. Secondly. 351 — In old age phases of do at as a rule. just as they other periods of The it depression is. There the same same self-accusatory attitude of mind. However. life. Senile much time and is patience are required. does not offer the same prospect of recovery. in its melancholia may make life. marked and extremely persistent. a the presence or absence of manic-depressive history of a previous attack of depression or perhaps of ex- pansion is of the utmost importance. upon a careful and detailed review of the patient's in order to determine elements. differs but httle middle symptomatology is from that of the melancholia hopelessness. ferential diagnosis from is senile dementia becomes therefore first. like senile melancholia. however. Because of the indifference of the patient and his not infrequent unwillingness to talk. important. life Like the melan- again. in the exam- ination of the patient. much more prolonged and. This to be based. the of life. it does not differ from that presented by the manic phase at other life. their appearance.

may merge into one another. and which are indeed frequently instances of exceedingly prolonged hypomanic states. rule. by relatively normal periods or attitude by periods is of depres- sion. BORDERLAND MANIC AND PARANOID STATES (The Mattoids) Among the first we may find cases clearly related to the manic-depressive group. Among these are to be found some of the unsuccessful. They separate themselves into two groups. and to the conditions with which he must cope. as a of will-power. to see things in their proper proportion or in their real relations to each other. as well as the immoral. it may be. At other times the mental distinctly paranoid. interrupted.CHAPTER III MENTAL DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY There remains to be considered a residue of mental cases which. to is the circumstances in which he placed. Every community contains its a number ives of individuals who make up proportion of defect- and deviates. the vicious. closely or adequately his Especially does he fail to appreciate own relation to the external world. though quite distinct. the misfits of society. and the criminal. but with this he betrays. great defects of is judgment and he fails His mental vision rarely clear. 352 The various undertakings in which . are notwithstand- ing clearly and definitely abnormal. though not classified among the insane. which. The individual often presents an appearance of brilliancy and originality.

howof friends is Sometunes he ever. He manifests or is no feeling for others. neglect of family and friends. vain. the money and relatives in this or that enterprise. Often he impresses his relatives and friends as though he were unusually bright. to He lacks the persistence. He self-absorbed. Slight obstacles discourage him and often lead to a radical change of plan. a long suffering mother or father. talks a great deal. egotistic. That he known. is held strictly accountable to the law is of course well 23 . and capable. Indiffer- ence to obligations. As the years go by. the strength of will. and betrays. obtain To lie. that he has little by his conversation and an expanded per- sonahty. and no is lost results are achieved. in any one occupation to acquire a thorough knowledge of He changes from one trade. Alcoholism often comphcates the picture. the idea that the atti- tude of mind is —a paranoid view of world ap- against him. and self-assertive. As a rule. a misanthropic hfe. Few closed who come into casual contact with such an individual realize his true condition. to swindle. the intimate facts can only be elicited from those the misfortune to live with him. Time. original. he usually often addicted to monologue. to money by devious paths of those are common The expedients. who have had Quite commonly even his family scout the idea of his not being mentally well. perhaps it is a single one. that he has been much abused —makes its pearance. rank dis- honesty are usual accompaniments. one employment. Failure the continual outcome. He enough it. latter is only dis- by a painstaking study of his history. no sym- pathy or consideration. who takes the opposite view. its logical complete or carry to conclusion a given undertaking. one caUing to another. passes is looked upon as a kind of genius.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 353 he engages are badly planned and doomed to rarely remains long failure. attitude. is At the same time.

results the arrest of development be general. there an absence of the conception of suffering or pain in others and an inability to take in moral or ethical ideas generally. there are no well-defined delusions. involving all of the mental faculties. stub- bom and callous. but terially in his who does not differ from them maIf conduct or in his relations to society. nothing that is clinically The inteUigence average. the condition most frequently met with is one in which the intelligence is fairly well preserved at least reveals in no deterioration to ordinary examination of feeling. STATES OF HIGH-GRADE DEFICIENCY. or that the arrest might be If quite unequal and irregular.— 354 MENTAL DISEASES factors That hereditary neuropathic cases need hardly be added. sometimes decidedly above the usual level. relatively slight. Manic or para- noid factors. There is an absence of the feeling for others which in normally expresses itself sympathy and altruism. of may be an but a well-behaved member of the community. are revealed either in the history. no hallucinations. such individuals are egotistic. or in the course of the examination. however. and at the same time an individual who is less capable. there be a lessened intelligence but a preservation of the the normal emotional reactions. are present in such reveals is The mental examination significant. —but of is which there are marked disorders and character. of will. as already pointed out. As children. however. self-willed. CRIMINALITY (The Morons) In considering arrested development in children. MORAL DEFICIENCY. the individual inefficient feelings. less fitted for the struggle of exist- ence than his fellows. it was pointed out that the arrest might be general in character. They are undemonstrative toward their . Unfortunately.

Being . what they are bidden They are easily angered. take their punishment without a murmur. are jealous. Then restlessness. They masturbate. correction. they may travel alone or may associate themselves with tramps and criminals. he roams through the country or goes by train from city to city. practice perversions. and. an interval. their parents The sorrow which when the may have because of their conduct makes no imlie. and cruel. At school they are lazy. and. and sometimes the child or j^outh dis- appears definitely. as a rule. at- tempt of is made to coerce them. or other institution. the sexual instinct is. They resist control. In children of this kind. Often they return home after a longer or shorter period of vagabondage. they run away from home and live by begging and theft. almost instinctive. Soon they become sometimes a gross infraction of the peace leads to the reformatory. an impulse for change. make no evident after explanation. have violent tempers. and indeed evince a dislike of being caressed. may repeat the escapade. invent self- lies. drives the individual place to place. of the classroom. pression upon them. disorganize the order incorrigibles. are indifferent alike to scolding or to praise. Quite often they evince a fondness for torturing animals and for maltreating their smaller playmates. Frequently the absences grow longer. from one distant place to another. is To They have their own way. resent discipline. so they become accentuated at this period.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 355 parents. or tell impossible stories. to disobey. vindictive. an unfrom mood. ress. In some cases the tendency to wander does not make evident until adult stable life is itself reached. sometimes do the exact opposite to do. commit assaults on little if Some- times these traits appear before puberty. pre- cociously developed. mislead other boys. at other times. make no prog- commit mischief. children.

and debauch. neglects. Occasionally he seeks emplojonent. he resorts to sorts of expedients to raise money. abuses. finds associates in the slums and by-ways. too. obtains goods under first false pretense. That murder may be included known. he meets with failure. Quite commonly he gives himself up to gambling. drafts upon his relations. they present the same history and incorrigibility in childhood. he certain lines of work for may end by becoming a professional may devote himself to which he has especial aptitude. and criminal. indulges in of company young men. when they are of lying. she has children. and may early fall into as she grows prostitution. if Perhaps she If married. scandal.356 MENTAL DISEASES all without funds. commits abortion. impractical. which he immediately sells. he may even acquire a special pride in his and achievements. he is entangled in the meshes of the law. escapades. More frequently he resorts to forged checks. At other times. the young woman up betrays inordinate vanity and love of finery. indeed. may sneak-thief. Sooner or in the list of his crimes is well later. She has risque adventures. At times he embarks on a career of crime. creates talk. pickpocket. Every possible resource exhausted. gossip. alcoholism. as is well-known. However. disobedience. She has an utter disregard of the husband's means or interests and makes life impossible . he marries. usually at the is available price. skill become bunco-steerer. Girls happily are less frequently the victims of this disorder. exploits his friends. manifest the same sexual precocity. or he consorts with prostitutes. afflicted. avoids pregnancy. burglar. but being poorly prepared. in one of his early escapades. and essentially dishonest. later perhaps commits bigamy. but usually in the She. of course. her affairs culminate in a runaway marriage. ill-treats or. Sometimes. them.

with feelings of pain. safe to say. morally. does not attract special attention. indeed. that the general intelligence portion to the moral sense. cit. by the intelli- Binet-Simon System. Breaches of the moral law are frequent. Quite commonly her desire for admira- tion leads her to encourage the society of other men. degradation. and crime are not associated right.) The may it be found below normal. it However. the natural result. of syphihs and general unphysiologic both men and women of this class may acquire some form of insanity necessithis is a tating asylum commitment. whatever the are. no feeling of right and wrong. irregularly examination usually shows developed." "moral insanity. namely. to be unequally and Every lazy and incorrigible child should be sube. at least not early in the case. jected to a thorough psychologic examination. The patient's intelligence it seems to the lay observer to be ordinary. not infrequent outcome. It is in this respect and the terms "moral idiocy. or even unusual." long ago used by English writers. associated with feelings of pleasure. good. be found subnormal. However..DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 357 by her extravagances. As a consequence of the abuse of alcohol. the true state of appreciated by the family. g. He may be. by his appetites by the temptations suflficiently of the moment. is of course. indeed. that in a large will number. and usually inteUigent to appreciate the consequences of his . facts elicited by such an examination is one fact remains. nor are ideas of duty. obedience The child has no an sense. preserved out of profeel The child cannot and does not Ideas of sin. The sufferers from this form of deficiency do not. The acts of the patient are determined exclusively or is. fair. divorce. loc. however. the infection living. gence It is (See Whipple. idiot. wrong. say about one- third. adequately designate its condition. nor. recognize their affairs own condition.

which. There first. (See p. a pronounced neuropathic heredity. though infrequently. second. roles. fest itself in various may is mani- forms of sexual perversion. insanity. If Improvement the individual seems to be possible lives. Equally well known the fact commonly the victim of a vicious heredity. and a history repeated commitments in is quite common. It not sur- prising to find defectives in whom the sexual factors constitute is. the prisoner often recurs. Prison discipline sometimes.358 acts. as soon as liberated. advancing years may bring some amelioration. in addition to masturbation. MENTAL DISEASES but this does not deter him from following his inclinations. bastardy. That a of arrest large number of criminals present physical stigmata was long ago pointed out by Lombroso. temptations less alluring. which crime. cial effect. desires are less keen. in the great majority of cases. a more or less marked mental de- ficiency which sometimes amounts to feeble-mindedness. and. is At times the mental deficiency not pronounced. though one can hardly subscribe fully to his interpretation of their significance normal — as such signs are occasionally found in otherwise known concerning the criminal's persons— enough is is mental make-up to justify the conclusion that he subnormal is and deviate that he in is in development. but in such cases the characteristics noted in the neurasthenic-neuropathic constitution are observed. there is. to his old of mode of life. only a limited number. the principal clinical features. has a beneis unfortunately. as well known. a heredity syphilis.) Third. 182. the pa- . in the larger number. and alcoholism play significant SEXUAL ABNORMALITIES In the preceding section fectives it was noted that high-grade dedevelopment of the frequently present precocious sexual instinct.

hand Among the more distressing sexual defectives are men in whom the sexual organs are of normal appearance.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY tient not infrequently bears 359 upon his person the stigmata of an aberrant development. Sexual abnormalities separate themselves roughly into two groups : first. this face. and. frequently. or that perhaps one or both testicles are testicles have is failed to descend. frame. ticles In pronounced cases the penis. second. impulse. scrotum. but this is of course not necessarily the case. too. musculature. and is manner suggest immaturity although the patient of adult age. In women in similar conditions are met with. and Sometimes an examination reveals that the penis unusually small. The hair on the pubis and in is the axilla hair apt to be sparse. fairly developed. commonly such patients are sterile from the beginning. and tesinfantile. true of the upon the also The skeleton. pituitary deficiency go Doubtless. Sometimes the sexual impulse and power are both entirely lacking. in Every physician meets with male patients whom there is more or less marked deficiency of sexual development. voice. the face is beardless. like that seen in pituitary deficiency. the voice child- remain hke. and the patient presents a diffuse deposit of fat. voice. those in which sexual evolution has been incomw^hich sexual evolution has been is plete. and in whom the secondary sexual characteristics —beard. those in aberrant so that the impulse inverted or perverted. and musculature —likewise life appear to be is but in whom the sexual feeble and short. and power. here testicular and in hand. more fre- quently the patient presents a history of fair sexual competence Quite extending over a few years and then premature failure. and they vary from those to those in whom there is marked failure of sexual evolution whom sexual evolution seems to approximate the .

divided into two groups. as a rule. she may show the evidences of an involvement of the internal secretions. i. that this invariable. MENTAL DISEASES In the former there may be a history of non-appearof menstruation. . the appearance may reveal nothing abnormal and yet the patient may lack be frigid. a rigid examination reveals that they are. first. frequently it is found that the man man presents certain man who falls in love with another physical peculiarities. those in which the impulse it is inverted. entirely sexual impulse. like those of and torso generally general physical a child. thus. second. The second group has of cases. she react for a while and then pass into a period of premature involution. those in which perverted. the presents many of the the pelvis and buttocks may may be unusually developed. ance or of late and imperfect appearance is Quite frequently the uterus infantile. the face beardless. shoulders. the hips. or the sexual act may be painful and disgusting. On the other hand. or apparently normal. this is to affection for the opposite sex. the voice feminine. the breasts are small. frequently.. however. hair pubic and axillary may be deficient. ideal and platonic.360 normal. Again. it somewhat subnormal mentally. Like the corresponding male patient. e. be female in type. presents quite commonly morphologic It is subis pecuUarities as well as abnormal sexual impulses. a premature menopause. Like the male patient. Both men and women of this group may display a well- marked tendency however. is cannot be claimed. Although it may anatomic features of woman. cases in The first includes instances of homosexual love. the vagina cleft. she may may unresponsive. that in which sexual evolution been aberrant. and the external genitalia exceedingly small. which the Quite sexual impulse is toward the same sex as the patient. again. the breasts be that the genitalia are normal.

strides. in obtaining for himself sexual gratification. stands. and in whom. the sexual impulse is inverted. Sometimes the act is one of indescribable bar- barity. Such persons may. the male kiUing his victim. so writer. In such cases the in- version of the instinct usually purely nervous and psychic. and yet have desperate love affairs with. there are individuals may be indulged in. has narrow hips and pelvis. at times. talks like a man. is Occasionally. Sexual perversion manifests sexual congress between ity. "necrois phily. and face. perhaps an unusual amount of hair on the indeed. As a rule. the person be a woman she as a rule. is. itself At times the perversion manifests termed after an Austrian insists as masochism. patients are with. however. a condition of the genitalia perfect differentiation found —an imOn the —suggesting met hermaphroditism. g.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 361 the gait mincing. too. an enlarged and erectile clitoris. however. physical gratification Again. examination reveals Sometimes. small breasts." Sadism. other hand. himself. cutting off breasts and genitals. e. and perhaps ending with cannibahsm. mutilating the body. human beings and animals. The male begs the on pain being inflicted upon He . in which the genital organs and the secondary sexual characteristics alike do not differ from the normal. some person of the is same sex. "mannish" in appearance. who fall in love at one time with a of member of the opposite sex and at another with a member the same sex. such persons play the passive If part in the abnormal congress. notwithstanding.." or sexual congress itself in a variety of ways. often with great cruelty. and abandon their families for. so-named after the Count de Sade. in both male and female homosexuals. Sacher-Masoch. "bestial- by a man with a dead body. inflicts a form of perversion in which the male pain and suffering upon the female. marry and bear children.

is most intense and apparently most will occasionally Such persons arm the woman and with a whip. may be met with. e. VT. a slipper. skirt. which the patient snips with a scissors. which she applies to the nates. is Exceedingly disgusting forms of this affection. Occasionally some part of the apparel of the female. or stitutes the entire sexual act. i. in some cases previous sexual excesses and exhaustion seem to play a it is role.. always the cardinal Sexual precocity. erections and orgasms moment the desired object is secured —the moment curl. of masturbation. is a very common symptom like. the When fragment of dress or the curl it is is thrown away afterward. origin in the formaI. as in defectives.362 MENTAL DISEASES to beat or maltreat woman him in various ways. pederasty. undergarment. or penis. the con- man having an orgasm and emission just as the pain difficult to bear. bestiaUty. too. otherwise retained. Sadism and mas- ochism are innate perversions. a curl or plat. Sometimes a fragment of a off a lock of hair. that the scissors cats through the dress or snips the this is the case. and their perversion has tion of pathologic associations. the sight or handling of or. shoe. it it is which leads to erection and ejaculation. to a paroxysm skirt. scrotum. and the or masturba- . which spoken of as fetichism. occur the quite commonly. may be.) The inherent neuropathy of the individual factor. and the act ends in intercourse. this either it induces an erection. This precocity may early lead to various forms of perversion. of psychasthenia. as when the patient preserves or cherishes the urine and dejecta of the female or actually swallows them. we have seen. at other times the individual will lie upon the floor insist^ on being stamped and trodden upon. Persons who suffer from fetichism not infrequently present the characthe neurasthenic-neuropathic its teristics of make-up. (See Part is Chap.

classifiable. the explanation. of sadism and masochism. The prognosis of sexual perversion. so that extraordinary stimuli are required to produce sexual gratification. on the one hand. of small doses of thyroid HYPOCHONDRIA Hypochondria. much may Sug- at times be accomplished by physiologic living accompanied by physical activity leading daily to normal fatigue. It. is when accompanied by of marked morphologic course unfavorable. notwithstanding. and there are cases which the male. employed. hypochondriacus. masturbates in her presence instead of having intercourse. merits here both a place and adequate consideration.— DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 363 tion and other excesses may result in sexual exhaustion. later writers speak of hypochondriasis and associate the conditions with complaints of the stomach and . also. This is probably. as already stated. speaks of morbus frankly with mental diseases. having actual access to the female. or lutein may be tried over a long period of time. when masturbation results. on the other. psychasthenia. itself in Sometimes fetichism manifests the patient desires is such a way in that all a sight of the female genitals or limbs. peculiarities. Hippocrates does not use the however." Galen. and hysteria —and. gestion and other forms of is psychotherapy should of course be of doubtful value. Hypnotism In simple sexual deficiency animal extracts. in part. term "hypochondria. spermin. When it it occurs in neurasthenic-neuropathic subjects. Occasionally the chain of the glands of internal secretion may be stimulated by the prolonged administration extract. or itself when manifests only as an occasional symptom. with the neuroses neurasthenia. is a borderland mental state. though far removed from the other topics treated in this chapter.

Schuele. pursues ality. Mendel. Griesinger. may be rated it from the other two affections. and in this he was followed by Mueller. it was confounded with hysteria. its Its symptom group is occurs alone and own course. hypochondriac. of Edinburgh. an increasing clinical knowledge has shown that hypochondria occurs indeit pendently of these affections. In the middle of the nineteenth century French writers. —followed. prodomal periods of melancholia. states. medical writers have been loath to grant to hypochondria a definite position in our nosology largely for the reason that hypochondriacal phases are observed in various mental affections such as the noia. Further. first clearly from the latter affection. recognized the mental character of the symptoms. however. Bouveret. German writers and many others to differentiate — Romberg. further. many it of the older writers regarded as the expression of this disease in the male. of para- and in various demented However. said to be hysteric. with melancholia. and others. Its symptoms owe change in the general sense . too. on the one hand. with neurasthenia and. in compliance with custom. on the other. hysteric. beginning with Georget. Hypochondria is frequently confounded. in his treatise on the nervous. clearly sepa- He says: "The complaints of the first of the above classes may be called simply nervous. that the presence of a single occurs without symptom of neurasthenia or of a single stigma of hysteria. It the expression of a diseased personin of an abnormal condition inherent their origin to a the individual. In 17G5 Robert Whyte.364 of digestion. and hypochondriac disorders. for a long time. until the latter part of the it eighteenth century that was more definitely recognized. and those of the third." We have here an instance of remarkable clarity of vision. Von Hoesslin was one of the it Jolly. It MENTAL DISEASES was not. those of the second.

Normally. at times. Sometimes comparatively mild. of They merely Further. bowels. commonly these are vague and generalized. and the latter directly affect the psychic state of the individual. the somatic impressions which dominate the consciousness. of not being well. and these impressions are feeling of illness. . all of the somatic processes concerned in the nutri- tion of the tissues and in the functions of the various organs. Owing to an inherent neu- ropathy in the individual. The sense of illness. it is give rise to a generahzed sense of the sensations evoked by the stimuli received from the external world through the various sense organs that normally dominate the field of consciousness. degree upon the field of The sum total of the impressions received gives rise to states of bodily feeling. the somatic field changes do not impress themselves vividly upon the consciousness. that the of such a character as to produce a mental attitude is subjective under these circumstances need hardly be added. and is in keeping with this the mental attitude of the individual In hypochondria. liver. may lead merely to it is an undue amount of com- At other times life very pronounced. It is important to point out further that actual physical disease or obvious disorders of function are not present. and in such instances plaining. less impress themselves to a greater or consciousness. however. they are quite definite and ap- proach visceral hallucinations in character. the somatic impressions evoke sensations that are pathological. varies greatly in degree it is in different cases. a change which gives rise to a fixed conviction of illness. feeling well. field of it is objective. The patient usually explains his condition by disease of the stomach. It more or less would appear that all of the various changes taking place in the body.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 365 of bodily well-being. on the other hand. and then domi- nates the and actions of the individual.

but in such case they form but a part.366 or other organs. in melancholia the itself explanation of the psychic suffering concerns ness. it marked or profound. however. Occasionally. be no Melancholia is difficulty in making a a phase of manicis depressive insanity. which occupy his mind. While hypochondria. hereditary in hypochondria. in terms of the delusion of the unpardonable In other words. spiritual ruin. life In the melancholia of middle —the so-called melancholia of involution — it is true that hypochondriacal ideas are frequently present. usually a very small part. . factors are quite common Not infrequently we receive a history of a similar affection in the father or other ancestor. and if functional disturbances are present. characterized by more or less psychic pain together with ideas of self-accusa- tion which are commonly expressed sin. but merely It a conclusion based upon his general feeling of illness. MENTAL DISEASES His belief is not founded upon pain or other is distressing sensations in the region complained of. it is Sometimes Quite a history of insanity or other nervous affection. In hypo- chondria. of the larger picture of self-accusation and sinfulness. has a wave-like course. these are slight and inconsequential and cannot be invoked to explain the mental condition patient. may suggest melancholia. There can. with sinful- moral unworthiness. the ideas of the patient relate solely to conditions of the body. is unquestionably hereditary and innate. It is the various feelings of the body and the various disorders which he body. a brother or other near relative suffers like the patient or has a history of nervousness or of mental disease. factors commonly hereditary neuropathic are pronounced. on the other hand. believes to exist in the As might be expected. of the it When the hypochondria is correct diagnosis. need to hardly be added that the most careful investigation reveal fails any evidences of actual organic changes. too.

or amount of alcohol. Soon he is not well. persons On the other hand. longer eats well or he eats too much. life denly abandons himself to a of ease. those Thus. idleness. such as an atonic indigestion or constipation. or he extends his quest by going abroad. Here he again consults physicians and ends by going Previous to from one well-known health resort to another. slight disturbances of function. allows himself an unaccustomed exercise. he no no longer entails an objective attitude of mind. Before long he becomes the victim of imaginary gradually develop a confirmed hypochondria. more common among it is who live narrow and restricted lives. students. changes from one to the other.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY its 367 development it is is favored by all forms of unphysiological living. furnish the groundwork of a nosoills phobia. in a striking The effect of idleness is sometimes illustrated life. of life Here the unfavorable of influences are the existence. the war such patients made veritable pilgrimages to Carlsbad of and to others of the numerous watering-places and cures Germany and Austria. for example. has no perhaps plays golf to the point of overfatigue. monotony and the daily sameness of occupation. The stimulus of work Further. the Again. and may He begins consulting physicians. manhas sud- ner in the hypochondriasis of middle previously been active and A man who who has accumulated means. and professional people whose lives are inactive and repressed. often goes from one city to another. for example. found among clerks. the want life absence of special interests or objects in are also predisposing causes. of doors it may be met with among who work out and who earn their living by physical labor. seeking the advice of this or that prominent specialist. Among other factors favoring the development of hypoall chondria are causes which depress the general physiological . laborers and farm hands. smokes more than formerly.

to be Later. Premonitory symptoms of a later appearing life. in concerned about his health. Thus. pronounced. in more mature years. that it not until it has had time to reaUze that has been hurt. which causes the reaction. let us repeat. sometimes as youth life. who much Sometimes the student becomes hypochondriacal to the extent of believing himself to be suffering from this or that disease which he has seen in the clinics. is It should be added that hypochondria of the more common among men. or. insufficient or Occasionally excessive food. suggestion plays a role. some insignificant hurt or In keeping with this is the fact that frequently such a child will not begin screaming until after some moments have elapsed is. inclined to nosophobia. but the mental make-up of the The tendency child to hypochondria is sometimes revealed as the grows up. It is is clear. is The individual is unusually afraid of physically timorous. the symptoms become more marked before forty. an injury has been received. may be. MENTAL DISEASES such as the abuse of alcohol and tobacco. it early adult life.368 level. or it is excessively frightened or reacts inordinately to bruise. physical indulgence. All other factors have merely an inciden- tal value. although some cases that have most pronounced and troublesome of the writer come under the observation have . Most commonly they are occasionally they do not reach their full development before middle life is reached. sometimes during youth. a child betrays unwonted alarm over some trifling illness. it is seen are now and then among in contact with medical students and others disease. hypochondria are not infrequently noted early in Thus. dissipation. merges into adult illness. a ready the develop- ment of the affection. It is not the physical pain child. that in all cases of hypochondria soil for there a pre-existing neuropathy.

or . at another. brane of the mouth. may give later way on to more and which may to become more or less fixed. As the hypochondria becomes more pronounced. He may be constantly afraid of catching cold. At times. water is taken in certain ways or in fixed quantities at definite times. or other unnecessary hand. his fear of disease of the stomach or bowels On the other may lead him to adopt a special dietary. if be progressive. or the case be more pronounced and confirmed.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 369 occurred in women. Very frequently. one and then another If the case is lauded for its virtues. so Finally. only to be resumed later on. tea. hair upon the limbs or body is breaking 24 off. these very articles insisted upon. in the conjunctiva. is the importance of this or that fruit at breakfast Shortly after. the skin tight. abdominal binders. is falling out. the patient affects the various table waters. coffee. is or. the anxiety of the patient about his health increases. however. the vague other sensations that are feelings of illness definite. he may adopt an exclusively vegetable diet of meat. articles. to which. feels cold. hypochondria. as is is the case in many other mental affections. more frequent among those who are unmarried. Thus. of acquiring disease of the chest or abdomen. may be tabooed. Thus. or alcoholic stimulants are rigidly excluded. or special kinds of bread. At other times. Not infrequently. chest protectors. he experiences burning sen- sations in the skin. first also. which he refers to the surface of the body or the mucous membranes. a diet containing an excessive amount it is More frequently a special class of foods which time. breakfast foods. affected or excluded. he usually adheres for a limited time only. At one much ado is made over cereals. in the mucous memis stiff. again. is The. The patient now describes various sensations. such patients come to the phys- ician wearing an excessive amount of clothing.

Not infrequently. of burning sensations vulva and vagina. He complains of pains in his limbs. He has distressing sensations which he refers to the liver or to his kidneys. in the bowels. or he has strange distressing or pain- ful sensations in the genitals. as the pain at The treatment. of pulsating sensations in the epigastrium or in the abdomen. the limbs ache. failing to induce his physicians to his testicles perform castration. Wollenberg cites a case in which the patient. or they are the seat of fine vibratory. his is frequently quite unable adequately to of Thus he complains feels as pressure about the head. He complains frequently of backache and of pain beneath the shoulder-blades. is too. however.370 is MENTAL DISEASES the seat of creeping sensations. in appearance. and ance is in crass contradiction with the grave illness of which he complains. or numb sensations. One of my patients it had one of his testicles removed because he declared pained inef- him beyond endurance. fails An examination of the patient to reveal any physical signs of moment. trembling. tract to More frequently his it is the digestive which the patient refers sensations. his physical development his appear- he is large of limb and great of stature. he has burning sensations in the stomach. however. the abdomen feels swollen. Sometimes bizarre sensations are complained referred to this or that part of the body. though now and then he is dehcate and neurotic As often. He complains of palpitation of the heart. which the patient describe. was once appeared in the remaining testicle. men complain in the of pain in the women. the head. the spine. the muscles are well developed fully and the muscular strength up to normal. is fine. they burn. fectual. testicles. the trunk. There is no . head though there were an iron weight pressing upon the top or iron bands about the temples or the back of the head. himself removed one of with a razor. of.

these symptoms may. It is a common experience to have them . however. be but slightly. together with constipation. the hypochondriac patient observes his functions. is Not infre- quently slight catarrh of the head and of the throat noted. however. He may carefully the character of the bowel movements. movements executed by the patient. the patient not infrequently believing that he has spermatorrhea. a coated tongue and some evidences of gastro-intestinal atony and catarrh. etc. and it when a knowledge of such a catarrh is possessed by the patient becomes a fruitful source for instance. of hypochondriac ideas. marked. There very infre- quently. of the evacuations. nor in any of the are. a belief of serious disease of the stom- ach or bowels. Beyond the indigestion and constipation no other visceral or somatic sign can. Most frequently an urine. Less frequently he observes the urine. as a rule. observing size.. upon slight gastric catarrh and constipation. is noticed. Now and then a coldness of the hands and feet.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 371 change in the reflexes. may believe that he developing consumption or other frightful and serious disease from which he will never recover. as a rule. True to constantly his fear of being ill. elaborate exami- nation reveals of the blood. Atonic indigestion and note constipation offer him abundant opportunity. exceptionally the latter is distinctly sub- normal. in the pupillary reactions. More frequently he founds. The mental examination results negatively. it is in turn care- fully studied and becomes a fruitful source of nosophobia. and feces also absolutely nothing. or slight lividity of the surface or other evidence of feebleness of the peripheral circulation. if at all. be detected. Very often hyjiochondriac patients keep their careful records of symptoms. be phosphatic. in so far as the general intelli- gence is concerned. stomach contents. color. the most minute details with regard to the form. is The patient. if it Now and then.

Bottle after bottle is consumed. increases his nosophobia. He frequently presents the history of having visited physician after physician in the vain attempt to obtain satisfaction as to his condition. and then draw and un- forth Uttle slips of paper plicity of on which they have noted a multisubjective. Slight palpitation of the heart convinces him that he has fatal heart disease. always trivial symptoms usually important. a pulsating sensation in the epigas- trium convinces him that he has an aneurysm. seat themselves. and then goes to phy- sician with his diagnosis fully prepared. or some drug. and subsequently displays a superficial knowledge of medical terms in speaking of his case. day His diagnoses vary from week to week or often from to day. or of all of these organs combined. to-morrow disease of the liver. and salves follow in their closets of his and the mantle and rooms are not infre- quently laden with empty or half -empty bottles and boxes.372 enter the physician's MENTAL DISEASES office. liniments. Later on he begins this or that to make his own diagnoses. or obtaining little relief from physicians. One is of the features of marked hypochondria is that the patient it always taking medicine of some kind or other. To-day he has disease of the stomach. he not in- frequently begins to treat himself. and he finds in the numerous quack and patent medicines so extensively advertised in this country a rich field for the gratification of his nosophobia. Finding little satis- faction. and all serve to convince him that he really a very sick Not infrequently he delves into medical books. first of this and then of that nostrum. . In manner and bearing the hypochondriac suggests a person gravely oppressed by illness. upon another occasion. Pills. that are formed from time to time are all is The varying diagnoses carefully noted by him. and generally incapable of verification. turn. man. may be a tonic. it is disease of the kidneys. a laxative. powders.

Long walks may be taken or fatiguing runs on the bicycle. and. cient exercise. in hot water. he may exercise excessively. as already stated. respiratory gymnastics. or. down many hours of the day. daily upon his plunges.. or. for is At other times he takes grossly insuffi- fearful of the slightest exertion. indeed. and may even be an epicure in his tastes. Often he entertains absurd views in regard to ventilation. for a time. Very often we find that the hjq^ochondriac. and he buys apparatus of various kinds. Frequently he bathes exspray. He has read. shower. has extreme views or extreme habits as regards physical exercise. He more frequently eats too much than too little. forms or odd forms of exercise. perhaps. cessively. very frequently maniall. steam or hot-air bath insists tried.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY 373 It is noticeable. Every form is of douche. that physical exercise is necessary to health. believes that he has serious disease of the keeping Thus. a man who liver stomach or not infrequently has an excellent appetite and eats with evident He may show excellent judgment in the selection of his dishes. fests an excessive fear of water and does not bathe at No . on the other hand. sad to relate. that such patients freall in quently present an appearance of health not at with the symptoms of which they complain. are allowed to become covered with dust. among other things. himself to be may actually go to bed. Extreme etc. which. comfort and enjoyment. and he this is now begins to devote himself to of exercise after another method of treatment. an insufficient amount of air into his Equally absurd may be his habits as to bathing. sleeping next to open windows. Most frequently he is devoted to room exercises. or. admitting room. believing may lie ill. or he bathes in cold. are affected by him. the quantity is not infrequently excessive. after a few weeks of desultory use. One system taken up.

The of his liver sation. symptoms are at times more pronounced and at times less pronounced. The patient grows thin. however. and sallow. the hope of definitely and permanently influ- . such as attacks of acute indigestion or perhaps acute febrile affections. and his bowels are the principle topic of his converof pills or the use of injections constitute life. and the skin and mucous membranes become dry. The bowel movemucus. Indeed. symptoms may recur and the patient period. To-day is it is some new form of but to-morrow it bowel irrigation. the bodily by little begins to suffer. too inconvenient. usually pursue an even course. ception in youth and early adult In cases in nutrition little which hypochondria is progressive. and he now becomes a disciple of the high enema. a true setting in. gray.374 procedure for is MENTAL DISEASES too absurd. exercise. Any passing fad for the time being satisfies his longing for treatment. no recurrence many cases also the hypochondria espeits in- fades with increasing years and ultimately disappears. His ideas condition ments are dry. cially is this the case with the hypochondria that has life. we have indicated. may pass cases. through again. or too unpleasant him to adopt. a another hypochondriacal In other permanent recovery In ever being manifested. may take place. rule. which persists for months or years. it need hardly be added. they remission Later. Its not. it As a It does pursues a course extending over many years. He no longer sweats readily. Occasionally its hurried by some intercurrent illness. extremely its course essentially chronic. as The onset of hypochondria gradual and evolution is is. The taking the all-important business of his In such cases. of and often there are excessive discharges are now exclusively concerned with himself. the may disappear altogether for a period. Constipation becomes more marked than ever.

the latter occurs alike Finally. the patient may be somewhat talented or It is may manifest ability in certain directions. pointed out. neither development nor education have anything to do for. 375 less and Finally. however. A slightly coated tongue or a fancied or unusual feature of the bowel movements alarm him. lives Notwithstanding. He observes himself most closely. intellectual Again. The two special forms most familiar to the and the sexual practitioner are respectively the gastro-intestinal form. the statements ings are out of all of the patient as to his suffer- proportion to the symptoms. it is may with in their early be only the increasing hypochondria that they become incapables. the clinical picture dominated by a special symptoms. is and this is clinically important. among and laborers and scholars. is usually present some atonic perhaps also slight gastric catarrh and constipation. This may be distinctly Indeed. itself in While hypochondria usually presents form above described. characteristic of the hypochondriac.DISEASES NOT ORDINARILY INCLUDED UNDER INSANITY encing the patient's condition becomes progressively less. subnormal. while slight indigestion may be accompanied by great sinking sensa- tions and sudden fright. as with hypochondria. These patients are the ones who adopt . set of it the generalized not infrequently assumes a special is that is. though not necessarily so. and. In the gastro-intestinal form the patient complains of various vague and distressing sensations referred to the abdo- men or to the digestive tract. a word remains to be said concerning the general mental make-up of the hypochondriac. hypochondria it is the least frequent of the neuroses. while there indigestion. it probably for this reason that is often remains unrecog- nized or mistaken for some other affection. that he lacks the ability or energy to finish work that he has begun. form. such persons quite successful.

as not to merit a detailed description. and espe- not the case. . in their zeal for each newly discovered dietary. and not infrequently the is belief in sexual deficiency or impotence based upon a previous masturbation. Such cases are correctly classified as is cases of "psychic" impotence. cially the belief that impotence exists lead to failure. nervousness. Sexual hypochondria more common in early youth. when marriage they prove to be entirely competent. never attempted the sexual act. the fear. As a rule. Its victims frequently believe themselves to be impotent. advocate and extol the same among their friends and acquaintances.. jections. it is unnecessary to say. medicine. etc. kneading of the abdomen. Quite commonly they are young men who have takes place. so common. This is equally the case whether the emissions are excessive or whether they are merely normal in their frequency. or procedure. even when the latter has been slight and Quite commonly the occurrence cleus of seminal emissions forms the nu- around which the hypochondria centers. and who find great satisfaction in the use of inexercises. insignificant. special and who. The sexual form of hypochondria is one of the most common forms met with.376 MENTAL DISEASES list extreme diets or curious rules as to eating. not infrequently they are engaged to be married. The sexual organs are. this is Every now and then. indeed. however. perfectly normal to physical examination. who exhaust the of laxatives.

g. which occur in Russia in our own day. instances in which two or more persons become insane simultaneously. second. In a similar way contagious. The following in- met with: is cases in which a single delusive is idea or notion imposed by a patient on a person who well. and there are of epidemics of hysteria numerous instances afforded by history —of are "demoniac possession" —occurring in Europe during and subsequent to the middle ages.. cases in his delusions is upon another cases in which there a transmission of states of depression and excitement. a relative or a nurse —inclose contact with an 377 . and. demics appear in schools. presents and. finally. third. cases in which a person e. we had occasion to refer to the fact that the patient sometimes imposes his delusions upon large 157. a little girl is attacked by hysteria. first. cases in which a series of delusions systematized in character are thus imposed. though it is itself in it a more concrete form. Often mysticism and hysteria still commingled in these epidemics. Contagion. however. hysteria is (See p. which one insane person imposes insane person. fifth. Every now and then physicians observe the Sometimes epi- contagiousness of hysteria in their patients. and soon others — perhaps a large number — are similarly affected.— CHAPTER IV INSANITY BY CONTAGION In considering mystic paranoia. fourth. occurs with sufficient fre- quency to demand a stances are brief consideration.) numbers of other and apparently sound persons. not common.

For example. when the mental disease becomes .378 MENTAL DISEASES insane patient becomes insane himself without. same it frequently they are heredity and is sisters. Two important factors First. there is always a predisposition on the part who is the subject of the contagion. but in which the justify the diagnosis of a do not communicated insanity. Such pre- disposition is usually assured by the fact that in by far the larger number of instances both the original patient and the one secondarily affected are members of the same family. of course. is a^^lways and degenerate and lacking can be safely maintained that a sound mind. He will probably have the sympathy and perhaps active support of children. the offers little any re- When It the two patients are not feeble secondary patient in individuality. Such a vulnerability is part and parcel of the heredity. indeed. and usually sistance to the ideas imposed. of the person sight appears. again is the secondary patient relatively weaker and less forceful if than the original patient. or of abuse on the part of his fellow-employees. related. apply here. insanity cannot be imposed by contagion upon The historic instances of great hysteric and mystic epidemics do not. is Second. It is his wife and only later. We have those milder instances. The first character of the contagion varies greatly. in which merely a delusive idea or is attitude facts transmitted to the second party. however. acquiring the mental symptoms of the patient. is A brief consideration of the subject reveals that it first more complex than at are at work. They are victims of the commonly of the same environment. a workman in the early period of the depressive phase of a paranoia returns to his home in the evenings complaining of unfair treatment on the part of his employer. necessary that the person who the victim of the contagion should present a certain degree of vulnerability to suggestion.

instances in which at least the patient's attitude has been accepted by the friend. Such cases are not. The of insanity of the patient may be so pronounced as to admit no possible doubt. litigation. by the also authorities. and daughter who have lived together Usually the form of insanity presented by is the primary patient that of a simple delusional lunacy. and there a remarkable uniformity in the general conduct and attitude. A far more serious instance is that in which a friend.INSANITY BY CONTAGION 379 evident and pronounced. mitted from a patient to a person previously In almost every instance the patients are relatives. though they are infrequent. is woman hears that a friend has been sent to an visits the friend. are transwell. they are. acquires the notion that a patient is really not insane and has been improperly committed. the victim of ill- treatment and conspiracy. but the belief in treatment and abuse by relatives. systematized in character. doctors. The second sister or patient sooner or later accepts the delusions of the is mother. endless trouble and annoyance to both relatives and physicians may be caused. That. most frequently they are sisters or a mother in close intimacy. under such circumstances. and has been wrongfully committed. has been greatly abused. For example. is well known. however. by the landlord. In such case the fact of insanity may ill- be reluctantly admitted by the friend. and asylum attendants may be adhered to. that the family ceases to share the patient's attitude. Instances of true contagion are met with in cases in which a group of delusional ideas. frequently not a relative. The paranoia thus communicated . attempts at rescue. a asylum. Expansive ideas may make their appearance. becomes convinced that the friend is not insane. Quite commonly the delusions are those of persecution by neighbors. of course. true instances of insanity by contagion.

it its appearance simultanebe two brothers. however. abandoned a prosperous hardware business in which they had been engaged as young men. to a primitive They.380 is MENTAL DISEASES of the simple non-hallucinatory form. known to the writer. that they come is under observation. close together and isolation seem to be a necessary part of the etiology. at may be in two sisters. or it may least it is impossible to fix upon one or the other as the original patient. such cases result in commitment only when the conduct of the two persons has in some outspoken way attracted the attention of the neighbors or of the authorities. aloofness. if commonly hallucina- tions are present they are usually not transmitted to the second patient. and that men could not be good and honest unless they returned of life. where they led lives of great . Our knowledge of the subject largely owing to the French." The cases are quite rare. seems to be accepted by the As a rule. however. that in early life that the civilization world was wicked and modem form was altogether wrong. Often they live undisturbed and separated from the world for for their many years. so that contagion seems here also to play a role. it is usually when they begin making absurd complaints and charges against neighbors. twins. who have applied to the condition the very expressive term of "folie communiquee. in one instance only had the patients been committed to an asylum. and isolation. their reality. or seek redress for their fancied wrongs from the police. shopkeepers. latter. both occurred between mother and daughter. therefore. became convinced insincere. Even here. two brothers. and others. is It is to this condition that the term "folic a deux" living especially applicable. In a remarkable instance. For a long time they are known only peculiarities. Occasionally the insanity makes ously. the writer has had but two instances under his own observation. retired to a farm.

working about . In an instance observed at the Insane Department of the Philadelphia Hospital some years ago a colored woman.INSANITY BY CONTAGION eccentricity. the farm in a condition of almost complete nudity they allowed the hair and beard to grow without hindrance. and although when they met led lives of great seclusion. though he failed. the attempt was not repeated. A case of melancholia sometimes communicates his depression to another person. of scientific rather than of practical inter- As a rule after the second patient has been separated from the first. occasionally they are husband and wife. . suffering apparently sister. the Both rapidly mother and the improved upon isolation. the original case running a somewhat . The phenomenon est. usually a relative. in the The ideas thus communicated are always paranoid. the communicated delusions fade and disappear. Both advanced age. suicide. from acute mania. affection The from which they suffered was evidently a paranoia simplex (the non-hallucinatory form of paranoia) occurring and developing simultaneously in twins. sister. 381 they wore almost no clothing. infected her mother and her of the secondary patients. lived upon raw and boiled vegetables. frequently the patients are sisters. At times a common this suicide is arranged and may even be carried out. States of excitement are also at times communicated especially may be the case if religious exaltation be present in the original patient. strangers they did not hesitate to lived to a rather expound their views. Conditions closely simulating mania may thus be communicated from one person to another. it is the more who imposes is his ideas upon his weaker neighbor. one of them during a period of depression attempted and. as in other instances of forceful lunatic communiquee. Instances in which one insane patient imposes his delusions upon another insane patient are occasionally observed asylums. folic and.

and this period life. and. The prognosis of communicated insanity depends. when the secondary patient has lived for especially if many years with the original patient. the adoles- cent period of as in the case of a daughter living with a paranoid mother. of course. added to the actual strain of nursis such a breakdown the person nursing the patient happens to be a mother or sister. is same heredity patient and shares with the latter an inherent predisposition to mental disease. if its occurrence. Instances in which persons who nurse or attend the insane It is become insane themselves are relatively rare. of the contamination. Under such circumstances depression. indeed may never relinquish them. However. there an added anxiety and emotional strain often most difficult to bear. ing. MENTAL DISEASES That hysteric excitement may be thus com- municated. exhaustion with painful confusion. . very in- frequent to observe a mental breakdown in an asylum at- tendant. and confinement. sister. for The danger of the is the greater as the because the example.382 longer course. we have already seen. in the majority of cases. upon the nature and degree the delusions never secure the Further. the secondary patient improves and finally recovers when isolation is instituted. same firm hold on the secondary patient as upon the primary. loss of sleep. now and then. notwithstanding its rarity. all observers will agree as to Somewhat more frequently do we note Here. the daughter may cling tenaciously to the delusions that she has acquired from the mother and. may finally ensue in the relative. has covered the formative.

Of this our every-day prejudices are striking 383 . is belief made up of a group of associated ideas. a complex. Such a group of ideas constitutes a comis In the case of a systematized delusion. however. limits us to a consider- ation of the essential and more prominent features of the false belief subject. a statesman entertains a group of associated ideas. of a The persistence or strength complex is often dependent upon the degree of the associated feehng or emotion. The object of the present volume. a complex upon which he plans experiments and investigations. a chemist. need not be stated that normal com- plexes health. the complex It of course pathologic.. view and the action of the individual. plex. his political and upon which he bases A business man his entertains a complex upon which he bases his business course or enterprise. We A have defined a delusion as a it is concerning which the person holding systematized delusive incapable of accepting evidence. g. belief which constitutes his policy.— PART III CHAPTER I THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS The field of psychology of insanity offers an interesting and inviting study. which is that of a purely clinical treatise. e. i. normal beliefs is —make up the psychic content in By a complex meant a group of associated ideas relating to a given subject: Sometimes such a complex domiof nates the mind and determines both the point e..

264) are every now and At then observed and can only be explained by dissociation. that the delusion constitutes a system of ideas there is itself. MENTAL DISEASES The complexes which a young man in love enter- tains concerning the object of his affection constitute another. A pathologic complex differs from a normal complex in that it is inaccessible to other and conflicting ideas. Thus. Again. the patient. or the dissociation may be of such a character as to result in a cleavage of the personality. presents complexes dealing with conspiracy and persecution. in the paranoid affections. of ideas In such a state. the patient dominated by a group which are entirely dissociated from those governing his actions in his normal condition. familiar instance of paranoia such a system dominates the field of itself. despite the com- mon place facts of his origin. there being no association between the two. There is an actual separaless tion of the personality into two parts. p. no matter how is. in as already pointed out 263). of his surroundings. life. insistently the latter may by be presented. Cases of more or persistent double personahty (see p. . the psychic representation of a limb or of one-half of the body may be cut out of the field of consciousness. between it and other groups In the a break. one time the of field of consciousness is occupied by one system complexes and at another time by another system. and. in the expansive phase. in the depressive phase. consciousness and excludes all factors in conflict with the patient believes in his royal birth.384 examples. different groups of ideas may occupy the field of con- sciousness during successive stages of a given disease. an absence of association. many (see other ways. complexes dealing with importance. and of his actual station in Dissociation manifests itself in hysteria. Thus. as in hysteric somnambulism and in is the somnambulism of hypnosis.

. In other words. The presence of a hallucination implies of itself a dissociation. doscopic. The impression produced that of a sensation of extraneous origin. unrelated. illusion.) . exalted station. is Here. no sharp separation.THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS noble birth. Chapter V. no sudden transition of ideas to the other. the expansive ideas crowd the depressive ideas from the field of consciousness gradually. as was pointed out. of the personality expresses Now and and then a separated portion writing. of something received from without. e. it is misinterpreted. or rather is Such instances are In the case of an association is of course rare.) The most by interesting anomalies of association are presented the neurasthenic-neuropathic disorders. for a time may co-exist. but they nevertheless occur. dissociation is imperfect and abnormal. however. There seems to be in an active delirium a rapidly and constantly shifting fragmentation of the personality. therefore. the impression not properly correlated. constantly changing.. the psychasthenias. (See p. and. by words. g. instead of the patient hearing words sentences. 25 (See Part I. Here the delusions are (see p. may be. and transient dissociations. is 385 (See Part I. Chapter VI. In such a case. 22. is exactly that of a hallucination. Among sociation other states which offer interesting examples of disis delirium. erroneously apperceived.) unsystematized.) There here. incomplete. his own hand may automatically write them. a separated portion of the personality addresses itself to the main body is of consciousness. itself in that is. the effect upon the main personality i. from one group they Indeed. The general consciousness does not know what the hand is about to write and exercises no volition or direction over the hand. fragmentary. the one distinguishing feature the formation of pathologic associations. kalei- Such a condition can only be explained on the basis of multiple. e. it 34 et seq. and.

The conflict may it. taneous generalized fear. is in short. at school. unfair advantage of a partner who has. If it disharmony. sexual acts. on the other hand.386 MENTAL DISEASES In part. the opportunity may have much to justify partner may be overconservative. sexual experiences and transgressions. it joins in If in harmony greatly with the and perhaps be in in some degree modifies it the current of thought. dread. The indi- vidual of may under such circumstances pass through a period stress. unprogressive. is probably as follows: Under normal circumstances a normal individual —that let it is in — a complex may enter without It only or hindrance into the field of consciousness. abhorrence. the course suggested by the idea . disgust. all kinds of occurrences. For instance. latter. e. The idea occurs to his mind. or there may be for a time an actual conflict between divergent groups of ideas. depends upon the trend of the psychic activity of the individual whether If so. the recollection of which unpleasant or painful or of which tries to forget.. and a hin- drance. the patient is ashamed and which he The mechanism by means is of which the pathologic association formed is. may modify the current of thought. dislike. of the proprieties. breaches of conduct. but meets there in conflict with other ideas based upon loyalty and affection. grouped with other complexes already there. worry and but finally in the normal individual a de- cision is reached. and the matter settled. peccadillos. it may been his life-long friend. Among these are such occurrences as a reprimand threatened punishment at home. or to a kindred painful emotional state. a hne of conduct determined upon. it enters or not at a given time into consciousness. a business man has the oppor- tunity of achieving success by taking an be. an unpleasant experience in business. various acts of the patient. be the quite severe. such associations may be referred to attacks of sponother occurrences giving rise to i.

never wholly disposed only to recur later in some new and unrecognized form. many of them are observed in normal in- dividuals. repressed. or. indeed. In pathologic states the reactions may be more complex. of in an apparently unexplained fear or obsession. Per- haps it makes its appearance in a feeling of uneasiness. Usually. may lead to an exaggeration of modesty e.— THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS might bring the friend and his family to 387 want. the troublesome complex altogether. of antipathy for his partner. links itself to other perhaps subconscious complexes. defensive. reaches the field of conscious- ness. of anxiety.. and which he is anxious to forget. or of some trick of habit or conduct about his office subconsciously based upon this antipathy. some strange movement. though it does so in a converted or distorted form. the . lem is thought out and definitely In a weak or neuro- pathic man of. the attempt at repression only partially it successful. The buried complex is still potential. the repression of the maternal instinct may lead to the lavish ex- penditure of the affections on cats. 190. however. The repression of complexes leads to interesting phenomena other than those revealed in neurasthenic-neuropathic and hysteric states. dogs. a tic. may be as a sense of pity for himself. protective. to prudery. must be clearly borne in mind.) Such reactions. (See p. it the idea may be put aside. and. or apparently senseless. it may it be. If the complex concerns some action of the individual. finally. Such phenom- ena are not observed in persons of a normal nervous make-up. the of which is memory unpleasant or painful. can only take place in individuals already the victims of a pre-existing neuropathy. may be suppressed consciousis may not be permitted to enter the field of ness at all. cause pain and suffering to innocent persons. and other pets. by an indirect pathway. Thus the constant repression of the sexual impulse i. In a normal individual the probsettled. Thus.

and she of her assertions. the sexual complex becomes so far separated from the general personality. she man. that. or. stories of a sexual nature. gossip." Quite frequently the patient in the early forties. indeed. She is herself sexually attracted to the does not consciously admit this fact. She may not have more repression of the sexual instinct than a passing acquaintance with the object of her thoughts. her physician has assaulted or seduced her or been guilty of other misconduct. but may become much farther developed. a passing remark. Soon these . and interprets an every-day greeting. may be. which sooner or later assume the character of annoyance and persecution. she believes. or near or at the menopause. and therefore attributed by the patient delusive ideas to some one person or per- sons without. is paying her attention. evolves a series of systematized delusions. other commonplace incident as Grad- proof that the ually she man is pursuing her with his attentions. The may not limit themselves merely to those of annoyance and persecution by the attentions of the supposed lover. It is this condition which Clouston termed "old maids' is insanity. the latter is usually quite unmindful of her existence.388 MENTAL DISEASES may lead a woman to attribute her repressed feelings to others. ascribes the feeling to the man and represses or On the contrary. as in the instance of a hallucination. jection" of the sexual feelings follows: The explanation is of such a "pro- probably to be explained as Long repressed. The patient begins to take an undue interest in rumors. She may imagine that every man is in love with her. may make her feel that she is being desired and sought after. it Thus the patient may believe that her minister or. it finally reacts upon the main body of conis sciousness like a separated portion of the personality. or she may center upon some one man who. may cite the most trifling incidents in proof of the sexual At times the repression complex presents another picture.

but a short step to ascribe insincerity. a new school has arisen in Vienna which. and by and Painful and re- means the hidden origin of various phobias. The which are almost always anonymous and usually grossly indecent and obscene. and wickor. when a man criticizes in others the faults he himself possesses when the fault happens to be associated with some unpleasant fact or memory of misconbetrays a financial duct of his own. These cases constitute the so-called "poisoned pen" cases of the public press and of the courts. In neuropathic persons the transition to delusions of conspiracy and persecution readily follows. various members of her social circle. may be addressed to the victims themselves.) The tendency is to project our own buried impulses and desires as . Little by little she becomes the vehicle and disseminator of these cloth. intimates. tales. under itself to the leadership of Freud. tion of various persons by letters. his condemnation becomes the more emphatic. to a certain group men or to a particular individual. has devoted of the neuroses the interpretation and allied states.THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS 389 concern her neighbors. A procedure was evolved which has received the rather imposing and suggestive its name of psychanalysis. . mouth. seen quite frequently in normal life. It is not an accident that the is man who trust sometimes unusually prominent in religious affairs. 167. (See also p. an ardent Sunday-school teacher. attitude At other by word of times. it edness to the rest of the world. dishonesty. she may secretly attack the reputalatter. usually woven out of the whole and she may finally end by becoming a virulent scandalinstead of evidencing her mental monger. other symptoms are supposed to be unraveled. or an It is austere pillar of the church. Of late years. and has been extended by Bleuler and Jung to the interpretation of the phenomena of dementia praecox. delusions. of may be. friends. or to numerous other persons.

Agrippa. He beUeved that animal magnetism bodies. dreams thus constitute a powerful factor In order that in the pro- duction of mental symptoms. that to say among them were various theories of animal magnetism. we should be able to form a proper judgment of both of the method and of the claims of its votaries. according to Freud. impulse or obsession has repressed origin in the memory of some sexual experience. advocated by Pompinatius. in and the had their practices in which superstition and magic played will the essential roles. To origin begin. in England. rel- atively simpler procedures. until Braid. who in 1774 employed magnets His results were in the treatment of every possible affection. in turn. though the theory of animal magnetism was denied. This method. Suffice it nor of the survivals of these in later days. and. every its phobia. further. introduced a formal method in which. Bacon. At the very outset of our inquiry into the method his disciples are obsessed becomes apparent that Freud and by the single factor of sex. These theories in due course found their in maximum exponent little Mesmer. In their eyes every symptom. Van Helmont. delusion. Paracelsus. and the patient —so it is claimed it — cured. was derived from the heavenly tises. survived. tion of the Space not permit of even the enumera- many mystic and religious practices of ancient times. it will be necessary to accord it a brief consideration. short of the marvelous. some sexual trauma dream has a sexual origin. as is His theories and prac- well known. every has a sexual content and a sexual significance. similar results were produced. and others.390 MENTAL DISEASES pressed memories are given free vent. with varying fortunes. received in childhood. he discovered that he could produce the same effects by passes and gestures. and his supply of magnets becoming exhausted. psychanalysis is an evolution from other and latter. which was characterized mainly .

in the is Indeed. in which. was originally known as braidism. He observed among other things that whenever he was successful in arousing in the patient the memory of the occurrence which had given if.— THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS 391 by fixation of the eyes upon a bright object. a matter of history. in turn. the mind was purged of its repressed. hypnosis was found to be merely a state of hysteria artificially evoked. but. with amnesia. That is. Breuer. How extensively hypnotism was employed is in the treatment of nervous affections so. that in the early 80's common with many other physicians the world over. to use his is own words.. vious induction of hypnotism this That was fully recognized by Breuer and Freud proved by the . was practising hypnotism. Breuer. so much indeed. and Breuer termed this proceeding Later he was joined by Sigmund Freud. that patients suffering from hysteria react same way without the preknown. as to make a special account unnecessary. of Vienna. be emphasized." artifically That memories evoked under hypnosis induced hysteria — are worthless and likewise well is fictitious a matter of common knowledge. e. This. let it elicit memory. painful catharsis. during the artificial sleep produced. in Suffice it to say. that the In due course. made under is use of ''medical suggestion" as done "in somnambulism i. hypnotized his patients and then tried to from them memories of past occurrences. rise to his (the patient's) special symptom. the patient could be induced to give a full account of the occurrence and also to give vent verbally to the associated emotion. in other words. suggestions of various kinds were made to the subject. It is significant further to add that in this procedure he did not rely solely upon the spontaneity of the patient. the symptom disappeared. gave way to hypnotism. and at the same time. in hypnosis it was discovered phenomena observed were identical with those of hysteria.

are identical conditions. sleep sugfor gestions and the like — it was impossible him to dispose of the hypnoid state. She is re- quested to she thinks tell it everything that comes into her mind. lesser The patient was placed upon her back upon a couch and was spared every possible muscular effort and every diverting sensory impression. or to relations of time or of cause which have so that results are obtained become disturbed. Let us pursue Freud's method a little farther. Freud which cannot be understood. for we have learned that hysteria and hypnosis Finally. Freud en- deavors to obtain access to the memories of the patient from the very earliest experiences of the latter onward. claims that no neurotic history can be elicited which does not . and catharsis the successive and intermediate phases. lapses of memory become apparent..— 392 fact that in their MENTAL DISEASES book "Studien ueber Hysterie" they speak of the "hypnoid states" of their patients. whether it important or unimportant. the technic instituted by Freud was such as to lead inevitably to a greater or induction of autohypnosis. while he no longer made use of braidism. an important modification: he dispensed with hypnotism and then renamed the procedure psychanalysis. as he beUeved. happens to be shameful In the very beginning of the account given by the patient. braidism. such as might disturb her in her concentration on her "internal psychic processes. and mesmerism. A moment's reflection will convince the reader that while Freud dispensed with formal hypnotism i." series In other words. Subsequently Freud made. passes. These may have to do with every-day occurrences which have been forgotten. hypnotism. whether seems rele- vant or senseless. psychanalysis of is but the final stage of a procedures of which animal magnetism was the beginning. e. She is especially requested not to suppress this idea any thought or idea because or painful.

the more pronounced is this transformation. If the patient be urged up these it is lapses of memory by an increased effort of at- tention. some sexual in childhood. appears. is gression. and that the physician makes such suggestions unintentionally and involuntarily there can be no doubt. that the ideas which if now occur are repressed with every effort. Further. and as the motive of this repression he recognizes feelings of aversion or dislike. He invariably finds the retrans- pressed memory some sexual misconduct.THE PSYCHOLOGIC INTERPRSTATION OF THE SYMPTOMS reveal amnesias of to fill 393 some form or other. He regards the ideas which appear under these circumstances as trans- as derivatives of the suppressed psychic pictures. until finally. the direct result of the resistance offered to their reproduction. The greater the resistance. How little re- liance can be placed upon the sayings of patients in hypnosis and the hypnoid state of hysteria has already been pointed out. has the character of "a conversation between two persons". The agents which have brought about this repression he believes he recognizes in the resistance which is offered to the memory reproduction. noted. had already been pointed out by Janet in his . formations of the same. that the patient responds readily to the slightest suggestion received from without goes without saying. says Freud. and the fact that the psychanalyst always finds that which he is seeking to find leaves no room of for doubt. the memory really of discomfort. It some sexual trauma experienced may be safely said that whatever of truth there in the relation of repressed complexes to the production of various mental symptoms. says Freud. The truth of the memories elicited from a patient under the above conditions may very justly be questioned. The seance. the patient experiences a marked sense From of this observation Freud concludes that the lapses or lacunse memory are the result of a mental action which he terms re- pression (Verdrangung).

according to Freud. at others by a repressed sexual desire. dream is are represented as The patient. a psychic material furnished which leads to the solution or unraveling of the dream.394 MENTAL DISEASES (See p. in thinking is over the substance of a dream. which under ordinary'' circumstances causes the patient to reject certain ideas from the communication. the recollection of which painful and which he tries to forget. Freud. and in so doing he is to communicate every idea without exception that occurs to him in connection with the dream. as It is this censor or critic. Ordinarily. has a manifest or apparent content. that which appears on the surface of the recital. Everj'^ dream." Freud believes that the symptoms always have of childhood. often of sup- pressed sexual desires. they have given the name "the libido. ac- cording to Freud. requested to make an oral statement of the dream or to give an account in writing. is To this sexual factor which at times represented by the memory of a sexual trauma. 187. The psychanalysts have uniformly failed to give to Janet's discovery recognition and have restricted all causes to the sexual factor. as already stated. latter is of occurrences in the patient's past is of which the ashamed. obsessions. Janet clearly indi- cated the role in the evolution of the phobias. a person thinking about a dream will reject this or that idea suggested by the dream as unimportant and as having no connection with the dream. and . if but the patient can withhold the critic. in a dream analysis. their origin in some passionate sexual aggression Others than myself have dwelt on the glaring inconsistency implied by the sexual immaturity of children and the intrinsic biologic improbability of this view. which in the fulfilled. further believes that in the study of dreams we have a method of access to repressed memories. These memories are always of sexual occurrences.) discussion of psychasthenia. states of indecision and the Uke. Freud calls it.

Further dreams reveal. a process of condensation. kernel of the problem. with the number of ideas revealed in the latent dream content. there is no situation which is not pieced together out of three or four impressions and experiences. in the It would seem that that which is most vivid but. when we compare the number of ideas contained in a dream. the material derived from the dream when the patient gives himself up to the unrestrained associa- tion of ideas which ensues when he dwells upon the dream. it becomes apparent that a very great condensation has taken place. of eliciting the latent During the process the dream content.. precisely in an obscure dream element that he finds the direct evidence of the most important dream thoughts. he terms "dream-displacement" or Traum- verschiebung. find a single factor of the We do not of dream content from which threads association do not lead into three or more different channels. says Freud. The ment. because thoughts themselves present which cannot revealed — cannot be spoken of to others —without the injury of most important con- . Thus. e.THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS 395 a latent content. tion of motives off in We ascertain the cause of this activa- when we realize that we be are compelled to break communicating the contents of a dream. ac- dream content would be the most important. i. it is cording to Freud's theory. to mind passes from the thoughts and conceptions right belongs to others which it by which have no claim to such an emit is phasis or importance. and this process which has to do with the concealment of the meaning of the dream and with making it unintelligible. This process. as written down from memory. to which Freud ascribes great importance. lies in the displaceis The essential condition of the displacement It is of the a purely psychologic one. nature of a play of motives or activation of motives. in addition.

siderations, personal



asserts that this is

true of the content of every dream; that every

dream contains








pursues the dream-thought for himself, he arrives finally at

thoughts which surprise him, which he did not


existed in

him, and which not only appear strange to him, but are also
unpleasant, and which he, for this reason, would energetically

Freud says that he cannot do otherwise than to suppose

that these thoughts are really present in his soul-life (his subconsciousness?),

and possess a

certain psychic

intensity or

energy, but, because they had been in a peculiar psychologic
situation, they could not

become known

to him;

i. e.,

could not

reach his consciousness.


terms this condition Verdrangung,


says he cannot refrain from concluding that

between the obscurity of the dream content and the condition
of repression there

a causal relationship, and he concludes

that the dreams had to be obscure in order that the tabooed

dream-thoughts should not reveal themselves.
sentation of the




serves to conceal the latter.

Freud believes that the dream-work, "Traumarbeit,"
of a series of psychic processes to


which the origin

of hysteric

symptoms, phobias, obsessions, and delusions are to be ascribed.
Condensation and especially displacement are characters never

wanting in the other processes as


Freud believes that a

whole train of phenomena of the every-day





unconscious mistakes in speech, in

simple acts and other errors


due to analogous psychic

Freud's therapeutic application of the dream consists in

having the patient submit himself to the procedure already


of allowing all of the thoughts suggested

by the

dream, no matter what their character, to find verbal expression,

and, just as in his method of free association, the suppressed,
painful, or shameful thought thus finds a vent.

Freud assumes

that even in the deepest sleep a certain degree of psychic

present which manifests


as a watchfulness or

guardianship over the sleeper.
or watchfulness concerns

This guardian-like attention


other things, with a

suppressed sexual desire, and forms with the latter the dream,
the dream being a compromise of this guardian-like attention

and suppressed
relief for




produced a kind of psychic

the suppressed desire, for the dream represents the

desire as fulfilled.




true that every

dream has a sexual content


be safely

left to

the sober testimony of



extremely probable that the method employed by Freud

of itself suggests the


of sexual occurrences



too, there is reason to believe that the


elicited is ficti-

The dream


so often retold

and rewritten

— usually after

visits to the



the material finally obtained

has about as

much value

as that obtained

by the other method;


into this material the psychanalyst, as before, reads the

phantasies of his


extremely probable, further, that the psychology of
as the psychanalysts

dreams is not nearly as complex
us believe.

would have




dream conceptions arise just as the
i. e.,

in the act of


of entering into conscious-

ness, or during such intervals or periods of sleep in

which the



relatively light, so that the level of consciousness

approached or perhaps nearly reached. There


every act of

awakening an intermediate twilight state

mind, usually very

but sometimes prolonged.


conceptions have their

origin apparently in

vague sensory impressions reaching the

imperfectly submerged consciousness from without;



At any
rate, their arrange-

at times they are somatic in origin.



some semblance

of order

and sequence occurs subseUsually, too, this arrangeis

quently to the act of awakening.



automatic, but such material

capable of endless

manipulation in the


of interpretation,

and when submitted

to the vagaries of a procedure indistinguishable in its character

from a hypnosis


yield anything that the psychanalyst



Another method of bringing to

light repressed or


that of the association test, applied

by Jung and


told that as soon as he hears a given

to utter at once the first

word or thought that

comes into



A series



then read to him, and

the time elapsing between the reading of the word and the reply

recorded by a stop-watch.




be found that the time


— the

reaction time

suddenly increased, as though
it is

there were a brief period of hesitation,
plex has been aroused.

probable that a cominvestigator

The word read by the

the stimulus word; the word uttered in reply, the reaction word;

and a word which betrays an increase
to be a complex indicator.


time reaction


ordinary reaction

may prove may require

between one and two seconds; say, from one and two-tenths to one

and eight-tenths seconds;
ened to three, four, or


the reaction time


suddenly length-

five seconds, there is reason to suspect

the existence of a repressed complex.


Ust of words should

be reasonably long, and should contain, in addition to miscellaneous words expressive of various objects and actions, also a
carefully selected

number, based upon the


which a

previous general study of the case has suggested to the examiner;
these words should be interspersed at irregular intervals.


addition to the increased time required, the reaction word


also be significant


the association be unusually obscure


or apparently non-existent.
after a reaction




also significant


word with increased time has been noted, delay,
observed in the next word or two


less in degree, is


would seem as though the patient had been


disturbed and the disturbance transmitted to the immediately




seems almost unnecessary to add that the

results attained



method are commonly quite

trivial and,

further and above


are again subject to the personal vagaries

of interpretation of the psychanalyst.

remains to summarize briefly some of the essential features

of the psychology advocated

by the freudian


In the


place they create out of nothing a censor, a wide awake


guarding the dream of the sleeper; secondly, they create an unconscious something which in like

manner guards us during the

waking period and shoves unpleasant and painful memories into
the subconscious.


completely the latter


when the


dividual has a real worry, such as a business reverse, a financial disaster,

the death of a beloved child,

or, it


be, the

recollection of a crime,
ly, all of

a matter of





phenomena observed


both dreams and waking

periods are interpreted in terms of the sexual desire, the libido.

Fourthly, the ideas presented by the dream or which are revealed
in the

waking period do not




appear to


but are

masked and


In other words, they are merely

sexual symbols.

As there

not a single object in the range of

human ken

to which a sexual significance cannot be ascribed,

the task of the psychanalyst
if it,


If the object

be elongated

perchance, have a cavity the question

already answered

may be a key,

a lock, a snake, an open


a lead pencil,

a cup, or anything else imaginable. The horse, too, and other ani-

mals are favorite symbols.
gest one thing

Further, at times the symbols sug-

and at other times the exact opposite.

One thing

is clear,

however; the interpretation always depends upon the

psychanalyst, upon his resourcefulness, the fertility of his imagination; in other words,



own, his autosuggestion.


conclusion already exists preformed in his mind that the patient


from repressed sexual memories; and that he


them goes without

Indeed, that he finds everything he

looking for

we have already

Frequently, the libido
scene; at other times

expressed in terms gross and ob-

it is,

as the psychanalysts explain, sublirefined,

mated; that





However, the objection to psychanalysis

not so


in its

details, as in the hopelessly illogical position of its votaries.



began with the theory of sexual traumas

in childhood;

these have

now been

carried back

by Ferenczi

into the period of


Further, in the act of passing through the

pelvis of its mother, the child

badly frightened, and the fear

which which

it it



the prototype of the attacks of fear from

suffers at later periods in its

Such attacks awake
the child finds
it is

memory of this birth fear. Further still,
At three

in a state of auto-eroticism.

or four years of age,

already sexually aggressive, and the dominating factor
cestuous love.



Indeed, from now on the "(Edipus complex"
its life.

plays a large role in

Henceforth the future of the indiAll of his tendencies, all



dominated by

his eroticism.

of his peculiarities

—good, bad, criminal—are

the result of the

In his dreams and in his neuroses, he rehearses not only
of the child,



but that of primitive man.


he have the

misfortune to suffer from an epileptic attack, the latter
plained as an overpowering of the moral consciousness


by the

criminal unconsciousness; the attack replaces the sinful sexual

Melancholia and mania, too, are explained as repressions
of sexual desire;
i. e.,

and displacement

of the




explained, on the other hand, as an irritation of the

anal erogenous zone, and, on the other, as an expression of




possible affection


explained by the


Hst recently furnished

by an American writer

cludes practically

diseases except the exanthemata.
of psychanalysis will

One word more and our consideration
have been completed.
It is

a favorite theme with psychanalj^sts
of the

draw an analogy between the evolution

body and the

evolution of the mind.

That the body

has, in the course of the

countless ages required for
successive stages

development, passed through many

and transformations

a deduction which rests

upon famiUar

facts furnished

by both phylogeny and ontogeny

by both

biological history as revealed

by comparative anatomy

and paleontology, on the one hand, and by embryology, on the

That the

brain, the organ of mind, has taken part in

this evolution goes, of course,

without saying; and that

like all

parts of the organism


bears in

structure the record of this



doubtless equally true.

must be

freely admitted,

that this must necessarily be true of the
tries to


as well.


perhaps what the psychanalyst

convey when he says

that the dream and the neuroses embrace not only the

of the

but also that of the savage and primitive man; or when

he states that the patient suffers from reminiscences of humanity

and that

his history




Stated in


fanciful phrases it

of the

means that our mental embryology like that body rehearses in a measure the various steps of the mental
While the probable and general truth of

evolution of the race.
this inference


be admitted, the psychanalyst now

short of the final conclusion, which


Just as the body

may reveal the

evidences of arrest and deviation of development,

may the


That such

arrests run parallel with arrests of

the brain


shown by our

studies of the brains of idiots




feeble-minded children; and
ing from the neuroses

when we

deal with patients suffer-

and mental

affections generally,
it is



dealing with individuals of are organically defective.


equally true that they

This in






by neuropathic and



neuroses, psychasthenia,
in the history of

and hypochondria present not only

heredity but also frequently upon the very person of the patient,

the evidences of an imperfect or a deviate development.


likewise, the neuroses in turn present deficiencies

deviations which give to each


symptomatology and
Claims of cure by


in each are innate

and developmental.

psychanalysis, are therefore, in these affections, as fallacious as
in the case of hypnosis.

One could with equal reason expect


cause a harelip or a cleft palate to
talking at

grow and become normal by
digit or a cervical rib

or to cause a

to disappear

by hypnotizing or psychanalyzing the



most, surface

symptoms alone can be played upon; the under-

lying basic condition can never be in the slightest degeee influenced.

(See also chapter on Treatment.)

Let us


turn our attention to the psychology of dementia
are at once impressed


by the

fact that in the be-

ginning the


are not those of dementia, but those of

confusion, just such


we should expect


a toxic


onset of

gradual, usually bearing the

character of a confusion, sometimes with elements of systematization

and accompanied by exhaustion. The elements

of confusion,

dissociation, hallucinations, illusions, unsystematized or feebly

systematized and fragmentary delusions, are


present in a

more or


dominant degree.

Years ago. Regis, Christian,



and others

frankly treated this mental state as a confusion, and this
interpretation which I have myself emphasized.



word that

Kraepelin frequently employs in describing
it is


which can only be rendered as confusion or dissociation. Admiting freely the
fact of confusion, however,

soon becomes

evident that other elements are present which



recognition of this fact
lies in


of the

utmost importance.


it I


a large measure the explanation of some of


symptoms which seem special or peculiar to dementia prsecox.



dementia prsecox, as


psychasthenia and in hys-

a diminution

in the activity of the field of consciousness.

Janet has expressed this idea by the words abaissement du niveau mental (lowering of the mental level)


have myself


various papers used the expression "reduction of the

field of

consciousness" to convey the same idea.


in discuss-

ing the psychology of the mental feebleness in dementia precox,

terms the end process of the disease an "apperceptive dementia."

do not think that



gained by the use of this term.


cording to Wundt, apperception

the special process by which

any psychic content
such a process


brought to clear apprehension.




must enter

— an

act of will, the

multiple qualities of the object or idea, the sensations, emotions,

and, as a corollary, the impulses to which these necessarily give

Evidently an apperception embraces





of the

factors of psychic activity,


to speak of

an apperceptive

dementia conveys


more than
it is

to speak of

dementia as a

Further, Weygandt,

to be noted, applies the term

only to the end process of dementia prsecox.





know and

as has already been emphasized,

not a


in the beginning,

but only in the more advanced

stages of the disease.
therefore, as

The term "apperceptive dementia"


Jung would have us

believe, the equivalent of

Janet's term, "depression of the mental level," and

strive to



by changing


into "apperceptive weakness" little


Janet's term, which

gained for the reasons already indicated,

forms the keystone of his conception of psychasthenia,
to the



state of the mind.




state of psychic adynamia.


exactly the idea that


veyed by the term "depression
dition of the
esses, is

of the





a conproc-


in which the force, the intensity of



The mind

in such a state

is like




instead of burning brightly,

reduced to embers,



barely glowing.



not a state, however, which necessarily

implies disintegration, deterioration, or dementia.


existence of such a diminished activity of the field of

consciousness can, I think, be admitted without hesitation.

essentially a state in

which the intensity, the vigor

of the

metabofic processes of the cortex are lessened; just such a state

we have

reason to believe exists in psychasthenia.

sympLet us


fully appreciate this fact, it illuminates


in the

tomatology of dementia praecox that seems obscure.
briefly consider


of the


The slowness

of speech

and poverty of thought which eventuate
in stupor, find their


in catatonia,


of explanation in

an adynamic



also true of fixation of position, stereotypy,


perseveration, verbigeration.
in the

Here the psychic current, which

normal mind



a river broad and deep and easily

flowing, has been reduced to a shallow, a narrow,

and a monoto-

nously trickling stream.
thing that remains in the

Continuous or interrupted, it is the only
field of


Jung and others

have thought that




due to the fact

that the entrance of other associations into the stream

inhibited or blocked; but surely dams, obstructions, are not



the beds of the tributary streams are dry, for

we must remember

that the cortex


adynamic as a whole.
of the cortex

would appear that the adynamic state

does not involve the latter equally or uniformly and, here and

now and

anon, tributary currents join what

is left

of the

main stream, but they do

so irregularly, at unusual points,

and at variance with the orderly sequence

normal psychic


find that instead of

normal associations, mere

sound associations, associations

of coarse resemblances,


mere contiguity are produced.


patient's utterances


be confused, disordered, incoherent, and this confusion becomes

more marked

in proportion as unrelated

complexes force them-

selves into the field of consciousness.




of course, equally evident

when the

patient writes letters or

attempts to express himself otherwise on paper.

may happen

that the field of consciousness



greatly reduced dynamically than the cortex as a whole or than

other portions of the latter.


it is

probable that under
field is so

normal conditions, the activity of the psychic


diffuses to

and beyond the boundaries

of consciousness,


the activity of the psychic

field is relatively



results dynamically that the direction of the diffusion


and that other



flow into the less resistant


probably consist of complexes

— of

groups of

associated ideas


greater relative

dynamic power.


they necessarily consist of complexes which have been repressed

not proved that they sometimes consist of complexes

representing wishes and things desired

very probable; that
in fear

they also represent things of which the patient stands

and dread

— complexes




— must



Negativism probably finds
every impulse or feeling


explanation in the fact that

represented in the psychic make-up,

not only by a positive complex, but also by
it is

exact opposite;

probable that the positive complex owes


its differentiation

from the general psychic material, which

thus becomes




would seem that

in the

lowered, adynamic state of the field of consciousness, the positive

complex cannot find expression; of necessity,


finds ex-

being dynamically stronger, flows into the


The symptom

to which Bleuler has given the


ambivalence, and which consists in the tendency of the patient
to give expression equally to opposing impulses, has,

seem, a similar explanation and need not detain us.
pointed out, however, that ambivalence




cousin to the


of indecision of the typical psychasthenic.


the abulia of catatonia also finds a ready explanation in the

adynamic mental


Further, the lack of inhibition, imspecial






rooted in the same condition.


particular picture presented

by a given case at a given time
and character

obviously linked with the nature

of the thought or psychic process that


ing in the narrowed field of consciousness.
for instance, that a tailor should

It is not surprising,





sewing or a



washing or wiping.

Our Freudian


however, see in such phenomena the persistence of repressed
sexual complexes.
Finally, the activity of the field of consciousness

may become

festation of

more and more reduced,


no outward mani-

any psychic activity

longer evident; under such

circumstances stupor, usually a catatonic stupor, supervenes.





dementia preecox are due

apparently to the toxic irritation of sensory areas of the cortex.
excitation resulting breaks in

an unrelated manner into the

field of


and the impression produced on the mind

of the patient

that of a sensation of extraneous origin.
refers the noises


wonder that the patient

and the voices to the

external world.

In such a case, a separate portion of the per-

sonality addresses itself to the

main body

of consciousness.

Very frequently, indeed, almost always,

visceral hallucinations


often sexual hallucinations are also present.






now mainly

of the hebephrenic

and cata-

tonic forms


often feebly held,

commonly disconnected

and disordered, and at most but poorly systematized.
fertile field,


what a wealth

of repressed sexual complexes,

they have yielded to the psychanalyst

need not say.

the portion of the cortex irritated by the toxin


be other

than a sensory area need hardly be pointed out.
long buried associations

In this



which have no relation

to the subject matter of the field of consciousness
in, just

— may break

as do hallucinations.

That such

associations are re-

garded as strangers by the psyche of the patient can also be
readily understood.

At other


owing to the low dynamic

tension of the field of consciousness, associations long



diffuse into the field,

stream of thought, and

may become incorporated with the may greatly modify the cHnical picture
and the

presented; and that this enters into the explanation of such

like is

as impulsivity, clownism, special gestures,

extremely probable.

Bleuler, in his article

on dementia prsecox in Aschaffenburg's

Handbuch der
of the


makes a most elaborate subdivision
I believe,

mental symptoms, a subdivision which


of illuminating the subject tends to
shall not, for instance, take

add to


up the subject

autism and autistic
in a convis-


To me


seems quite natural that a patient
suffering with

dition of psychic

adynamia and


ceral or, better, ccenesthetic hallucinations, should be taken


with his

own world





persecutions or





our Freudians translate into wish fulfilments.

defensive ments. Bleuler has invented and proposed the name "schizophrenia." which he be preferable to dementia prsecox. The theory of a reduction of the field of consciousness is as applicable to the explanation of hysteria and hypnosis as to dementia prsecox. for term "auto-erotism". a toxic metabolism. but it employs in its stead the is difficult. To talk of psychanalysis as a treatment for a patient with the earmarks of a defective development. to all. in my judgment. (see p. believes to seen. tells us. understand the psychanalyst's as Bleuler says the only treat- attitude at especially when is ment he for dementia prsecox as the the psychic treatment. symptomatology dominated by the complexes. a sexual character as instance. and what not. It is not improbis that the nerve substance in dementia prsecox inherently defective and feeble in resistance. They occur in many forms of mental disease. very much like attempt- a broken leg or a typhoid fever by the same method. is In dementia prsecox the depression of the apparently due to a toxin. Because of his interpretation of dementia prsecox as a cleav- age or fissuration of the psychic functions. and as these enable us to penetrate into the psyche of the patient.408 MENTAL DISEASES cannot understand. also. as we have cleavages and fissurations of the personality are not confined to dementia. Freud. for that matter. ing to treat is. we should expect to be able in this manner to influence them. fer- a positive Wassermann. prsecox. as well as in the neuroses. the term . 131). However. however. is why this autism should be given done by the psj^chanalysts. the result of the ingress into the blood of an abnormal hormone from the sex glands able. to my mind. a defensive fer- cortical activity ment. of the disease is Inasmuch. and yet how widely these affections differ! This difference the Freudian theory of repressed complexes fails to explain.

a diseased personal- ity cannot be gainsaid. to the things he actually sees and hears. The above logical. during which depressing somatic hallucina- tory feelings give way to fictitious feelings of strength and power. a matter of clinical observation. is diseased. sensitive. the victim of abnormal is of somatic and other hallucinations. again not sur- The is change of personality. It is exceedingly probable that the psychology of paranoia does not differ radically from that of dementia praecox. Further. the personality itself.THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS 409 being of such general significance offers no advantages over dementia prsecox and should be rejected. feelings and that he should attribute morbid follows. to much more say the than that offered by the psychanalysts. logically These feelings act just as do frank hallucinations and address themselves to the main body of his consciousness as a separate portion of the personality. interpretation seems to the writer least. and taken up with that the complexes arising is should sooner or later deal with persecution prising. Indeed. That is we have an inherently defective individual to deal with evidenced both by his heredity and by his person. and illusory to the same source. esthetic sensations. That he has a morbid. is Further. it would seem. that even in paranoia vera the patient feelings. exactly what we his would be led to expect. the transition to the expanprobably due to a change in the feelings. is not surprising. and that under these circumstances he should react abnormally to his experiences. the coen- sive phase. that he should regard the various happenings of the external world as bearing directly upon himself is. his followers see nothing The fact that Freud and but the libido has led them to interpret paranoia as the manifestation of an un- . is perhaps this change tion of the patient in his in keeping with the increasing degenera- and consonant with retrogressive changes metabolism.

the instinct of perpetuation of the species. Finally. The primal in- may be enumerated as follows — the instinct of self- preservation. on the other. and. and in the experience of the writer they have not been homosexual. he has not slain him because of unrequited homo- sexual love. as in alcoholic para- the patient slays the wife or the mistress I whom he believes has been unfaithful. noia. with phobias and obsessions . Surely the facts of experience flatly contra- Of the large number of criminal insane recall which it has been my fortune to study I cannot a single instance Sexual factors in which such an explanation would apply. ruining. are. in know of no parallel instance which the victim was a man. the instinct of communal preservation and perpetuation. of delusions relating to food. and the digestive function. latter. when we analyze the primal instincts of mankind. the great mass poisons. it is true. sexual factors do not assume the preponderating importance which the Freudians would have us stincts believe. second. but because he has failed to return the homosexual love of the patient! dict this position. on the one hand. here deal first with hypochon- driac states (see p.410 MENTAL DISEASES if requited homosexual love. not infrequent in female paranoiacs. first. has made life impossible. it not because the latter has been defaming. We have. but they are In rarely homosexual. When sexual factors enter. and the protection factors are found Complexes dealing with these among the insane in great number. poisoning the patient. is a paranoiac slays his victim. embraces the taking of food The instinct of self-preservation of the person. The instinct of perpetua- tion of the species embraces the complexes dealing with the sexual life. The patient has slain his victim because the by his machinations and persecution. men sexual factors are much less fre- quent. The complexes . the de- lusions relating to physical safety. third. 376) second.

with manifold delusions dealing with sexual love. Gradually the breach between the patient until.— THE PSYCHOLOGIC INTERPRETATION OF THE SYMPTOMS 411 and lastly. The as for it instinct of communal preservation and perpetuation. he believes that he of special birth. would aUke be a hopeless as well as an unnecessary task to attempt to enu- merate them. therefore. the is instinct of herding together man in a gregarious animal —embraces a mass of complexes The re- which number and variety greatly exceed those of the other primal instincts. lations of the individual to the community in which he It lives are multiple and complicated in the extreme. Further. That such ideas may is be evolved under a matter of com- an almost infinite variety of circumstances mon experience. these relations are exceedingly close of function unceasing. but that he of his and creates about himself a world own. not of them. become fixed and . we have seen. breaks with is his surroundings as soon as the idea is bred in his mind that he being persecuted. or had best be termed. in- the complexes of which. in his progressive is and those about him widens mental is degeneration. his and the interchange Lesions. between the individual and frequent. as accessible. who is jostled or by his fellows or criticized by his employer. numerous as these admittedly are. jibed surroundings are relatively The workman who falls Ijehind.

the thyroid. and ovaries. the testes. so great. for arrests is and irregu- pathologic changes. is that the neuropathy to be ascribed to other causes negligible quantity. Insanity when once established offers in a large of cases so little prospect of improvement or recovery it is is that prevention becomes of prime importance. tuberculosis. 412 not surprising. the pituitary. . We know that upon the integrity of these glands depends the harmonious and full development of the organism. such as alcohol. the nervous apparatus and viscera generally. These causes em- brace all influences which impair or damage the organism. in the ancestry. among tions these are syphilis. human race is to win some of greatest victories. rather than that of cure. alcohol. due to causes active. That they should be is vulnerable to a toxic agent. Neuropathy. which but another word for imperfect larities. and the infec- and intoxications generally. is The role played by syphilis and alcohol of overwhelming importance. It is almost a extremely probable that alcohol acts not only by damag- ing the blood-vessels. for the most part. but directly influences the ductless glands.PART IV CHAPTER I TREATMENT PREVENTION Under number the head of treatment it is important first to consider prevention. for and deviate development. indeed. the heart. that the its in this field. minute or gross.

and of the future lies. wake. Unfortunately. syi3hilis and alcohol which stand prominently forth as the it is great causes. it syphilis also acts in an- other way. in their prevention that the great hope Physicians should. the advice . cocain. idiocy. damages the organism as a whole. may play a role in the apparent. Syphilis. may be in this directly transmitted to the and way it exercises a widespread and baneall ful influence. compared with those of chronic alcoholic abuse. we have Tuberculosis. kinds may be traced to However. we know. and is not of is itself a primary cause As regards the acute infections. of course. the various acute infectious diseases. in its weakness and degeneration naturally follow nally. if so their role in is less Tu- it is true. is so small that they play no obvious or imIt is portant role in the production of inherited neuropathy. as well as the intoxications other than alcohol. weakening of stocks. there no direct evidence that from parent they exercise deteriorating to offspring. advise against marriage either party has a neuropathic ancestry or is when only the victim of is an inherited neuropathy. Fi- we find that syphilis and alcohol are very frequently associated. but extremely likely that this vulnerability is secondary to a weakened power of resistance of the organism. as offspring. its no longer possible for the organism to transmit to progeny the same potentiality of development as in health. an impairment which reason to believe persists through generations. imbecility. and in their combined action we have a most potent cause for impairment. Like alcohol. notably in dementia prsecox.TREATMENT and it is 413 it is probable that when they are thus damaged. and other drugs the number of cases. but berculosis is. effects transmissible In intoxication by morphin. met with a large number of the it is insane. high-grade deficiencies of it.

nervous may be. however. Again. in- more common but it should never be advocated under the conditions we have just considered. on the commimity by the free propagation of the degendifficulty erate and criminal classes can with Much can. be accomplished by the isolation of these unfortunates. the expedients that are frequently advocated for the is prevention of insanity It would sterilization. there can. especially in dangerous. is Time and again the physician of the education confronted with the problem it and training of a child. a heredity without taint appears to be the exception. unfortunately. However.414 MENTAL DISEASES If it is life infrequently accepted. to say the opinion. the patient a woman. in the human race. Among law. marriage is between if the stock bears a neuropathic strain. in the absence of such strain. the In the case of the chronic insane and the deisolation is may be made practically permanent. especially cousins. carefully regulated is by appear that there no sound or ethical objection to its application in the case of patients who are repeatedly under the care of institutions for confirmed psychoses. to guard the child hygienically from Efforts should be its made As far early infancy. or the victim of a neuropathic heredity. or who are morons. mattoids. if insanity if is already established is it is bad for the patient. this not the case with the criminal. effect The baneful be estimated. an opposite However. we should at least like- urge delay until adult has been well entered and the lihood of an inherited psychosis manifesting itself diminished. justify domestic animals do not. or confirmed criminals. on physiologic grounds. The results of the interbreeding of least. fectives. rejected. Marriage sanity is is sometimes advocated by physicians because in the unmarried. as possible the exhausting influence of long-continued internal . Finally. be no objection. the presence of a clear family history.

TREATMENT 415 disturbances. as to determine whether there has been any increase in the basic mental power. It results used as is a guide in the future wise. the subject matter should be of such a character as appeals to a child. both mentally and physically. Later. Thus. we should remember that be lim- nervous children become exhausted very readily. with play. As far as possible school tasks should ited to the school-room and the work should be interspersed air. or. of repeated childhood infections. and care should it be taken not to make self-conscious. also. That such a child stands is being teased. and If other natural branches with simple apparatus and models. taught to read. manual training and more serious mental work should be attempted. to repeat this examina- tion at intervals of a year or two. geography from large and small globes. least of in the eyes of its comrades. As the child approaches the years of school great care should be exercised to prevent undue mental strain. and should be made humanly interesting and attractive. should not necessitate abstract conceptions. The nervous or done which all. nothing should be said demeans the child in its own eyes. The child should first be submitted to a thorough psychologic examination. the child should be taught elementary natural history from the actual objects. drawing. of attacks of convulsions. or made fun of very badly a common . not so much to determine the existing state of the child's training. and the course of education. and may be made the basis of a story by the teacher. jibed. with diversion in the open The work itself should be presented in a concrete form. physics. In devising a plan of education. child is apt to be very sensitive. molding in clay. The teaching should always include something which experience has taught appeals to the child. should be combated. preferably by the Binet- Simon system.

On general principles. with severe examinations during the student period and usually entails a life of more or less tension and strain afterward. in the country. of educat- ing it to a sense of its responsibility to the teacher. at the same time. should be faithfully carried out. and that physical exercise and the In companionship of wholesome playmates are not lacking. but. be. the physician should advise against any calling involving much strain. If the child remains well. should be taught self-control. grows up. effect In this connection should be mentioned the bad severe examinations held periodically in most of the schools. initiative and it will power should be strengthened. Usually children of a neuropathic heredity are unfitted for a professional career. depends upon the teacher how far to go. On the other hand. Care should be taken that the summer vacations are spent. It should be taught gradually to rely upon itself. work is bad. difficult The latter is perhaps the most task before the teacher. and especially the menstrual epoch. work on a farm. the wholesome discipline of teaching the child to do its part at school. corrected. the life should be made as normal as possible. excessive of course. MENTAL DISEASES While this care is being exercised. As the years of puberty are approached. if possible. other words. The child's spontaneity should its not be as best Its suppressed. and the time for choosing an occupation approaches. Such a career necessitates hard mental application. but it it should be encouraged to do work can. the fact should be is less borne in mind that during this time the child doing fatiguing work. if capable of is this true of girls daring Masturbation should when discovered possible. be avoided. the occupation of florist or fruit . Coddling and indulgence must. fatigue and the habit of inattention beafter all it come established.416 experience.

is attended by a it is serious responsibility for the practitioner. as far as possible. large number of cases this question almost decides is the case. the inclinations of the individual must be followed. It is exceed- ingly annoying. is 417 far as practi- greatly to be preferred. self to In the first place. has subsided in a few days into the asylum. but also upon the eventual course to be pursued. and also delusional lunacy. as is usually the case.TREATMENT grower. to a physician to find that he has committed a patient to an asylum who was merely actively delirious. and in whom the delirium. itself. for instance. and in which the man feels that he out of place. The depression caused by ises is a hated occupation. for instance. diately there comes Almost immeIn a This up the question as to commitment. who sees the patient and it devolves upon him to decide not only upon the immediate care and treatment. sufficient He should always upon least time to make a proper examination and Even in cases attended at an approximate diagnosis. in acute mania and in other forms of in mental disturbance with excitement. EXTRAMURAL TREATMENT A from knowledge of the management and treatment is of mental disorders on the part of the practising physician his calling. however. inseparable It is invariably the general practitioner first. most cases of Commitment. one which prom- nothing for the future. as cable. However. for and necessary of im- him to act cautiously and to bear in mind a number portant points. often exercises a most disastrous effect. the safety of the patient and of those about him. 27 —perhaps shortly after the admission In such an instance the friends and relatives . Naturally the first object is to insure. he should never allow himinsist be harried as to commitment. by marked excitement should he observe this rule.

advised. ing commitment While the intramural cases—those requir—constitute by far the larger number. it is commitment should be advised when evident that the treatment cannot be carried on satisfactorily outside of an institution. or less frequently. second. A mania. If so. commitment should be Second. as to the actual existence of insanity. having been examined and the diagnosis of insanity having been made. the physician should take sufficient time to satisfy himself thoroughly. arises. therefore. A delirium has a duration of a few hours. the physician should next consider whether the patient is dangerous to himself or others. no matter how icians in slight. a little reflection will convince us that the is number of extramural cases by no means small. It is acted hastily and of having needlessly placed the stigma of insanity upon the patient and the necessary. a week or two.418 MENTAL DISEASES active in insisting who were upon commitment may be the very ones to lay blame upon the physician —to accuse him of having patient's family. It becomes evident that cases of insanity separate them- selves naturally into two great groups. and. Further.) It is of importance always to act dehberately and to illness avoid haste unless the facts of the is from which the patient great. The legal responsibility of phys- making commitment should always be borne in mind. the intramural and the extramural cases. The physician should invariably decline to commit whenever any doubt. (See has a duration extending over three or more months. 92. p. The patient. several days. in all cases in which the patient neither dangerous nor violent. as to the advisability of commitment. suffering are very evident and urgency be is Certainly. first. other things equal. that the physician should be able to make a differential diagnosis between a mere delirium and a mania. on the other hand. even the cases which become intramural are in the hands of the practitioner for a shorter or .

and some forms of dementia. interval no treatment whatever should be instituted. neurasthenic-neuropathic insanities. other dehria which to treat. mild melancholia. pneumonia. Here the is. 419 Let us briefly turn our attention first to this group of cases. it is upon the physician is these are delirium grave. The delirium which accompanies the ordinary febrile affec- tions. The treatment and management incumbent of the underlying disease. etc. for had best be avoided or resorted to only in example. which fortunately very rare. grip. though the latter course is usually not necessary.). those which are not attended by much Drugs as. The transfer to the asylum should be In the accomplished as soon and as expeditiously as possible. There are. that depression. the various exanthemata and infectious diseases. As soon as the decision to commit has been reached. may devolve upon the members of the family. the mild and harmless paranoia. alone concerns the physician. and the deliria which follow the abuse of certains poisons. such as mild senile dementia. however. to choose between and gross physical The is. come on during the convalescent such as typhoid fever. erysipelas. rule should be followed to give the milder drugs. the This duty patient should be carefully watched. Only exceptionally is it necessary to give some sedative to moderate or allay excitement. some cases of dementia prsecox.TREATMENT longer period previous to commitment. cases which cannot or should not be committed various — that the extramural cases — comprise the transient deliria. their use when we have restraint. such as . Let us turn our attention to the treatment of this group of cases. rarely requires special treatment. emergency. the postfebrile deliria (the deliria which periods of infectious diseases. or it may be necessary for the time being to employ a trained nurse. as a rule.

In delirium of marked severity. and the administration. the most efficient form of hydro- therapy a prolonged warm immersion bath. act as diuretics. Much more serviceable and. the main- tenance of the nervous strength. . and nervous sedatives. The means at our command consist in the adminis- tration of liquids in large quantities. in some cases. second. the delirium be afebrile. some poison introduced from without. having been thor- oughly and closely wrapped. as fectious is usually the case in the postin- and is toxic deliria. with a marked diminution of the excitement. MENTAL DISEASES The management of a dehrium should be conducted upon general principles. nervous exhaustion. If fever be present. The patient. We should bear in mind that we have to deal with two underlying pathologic factors— first. the free administration of nourishment. blankets are applied over the sheet and the patient allowed to remain hour. of course. the allaying of may be necessary. second. however. while the action of the skin is stimulated by the bathing. The temperaHowever. As much as pos- must be met promptly and simultane- ously.i20 alcohol. to carry a struggling patient to a bathroom and subject him to the strain of the necessary handling and manipulation. in ordinary household practice a It is warm immersion bath can not practicable. only exceptionally be used. as a rule. the excitement so far as sible these indications and third. instead of being dipped in cold water. the free use of baths. profuse diaphoresis results. the toxin of some infectious disease or hol. save that the sheet. should be dipped in warm water. and. such as alco- The treatment first. resolves itself into the following indica- tions: the elimination of the poison. cold spongif. more efficacious is the wet pack. ture of such a bath should range from 90° to 95° F. ing or other forms of cold bathing are appUcable. in the pack for about an As a rule. of cardiac stimulants Liquids. This should be given in the ordinary way. when necessary.

and.. It is of the utmost importance in many cases. often proves efficacious in so small If a dose as 3 grs. of being somewhat uncertain is and while by many writers scopolamin considered to be identical with hyoscin. of the latter. trional with sul- phonal. much well- No founded objection can be made to their judicious employment. The necessary manipulations add greatly is to the confusion suffering. better still. 15 or 20 grs. a dose of trional.. in the experience of the writer scopolamin is a much more it cer- tain remedy.. Lumi- nal. both the wet pack and the immersion bath have serious drawbacks. with sulphonal. 10 grs. The writer. this caution necessary in cases in which the deUrium in somewhat prolonged and in cases which exhaustion is a marked factor. can be administered. Hyoscin has the disadvantage in its action. and is perhaps the sedative of election. or. to administer sedatives. the question arises whether some form of hypo- dermic medication should not be practised. and excitement from which the patient and may in this way greatly aggravate the exhaustion. the excitement be very great. Occasionally medinal 10 grs. of the former with 10 or 15 grs. sodium). especially if the delirium be violent and the patient be expending strength in his struggles. or veronal.. however. the patient can be induced to swallow. 15 or 20 grs. for the quiet and sleep produced are of the utmost benefit.TREATMENT 421 however. which has of late years been added to our armamentarium and which belongs to the veronal group. if As a rule the milder hypnotics prove efficacious. neither the wet pack nor the immersion bath should be repeated too often. The sweating from the wet pack should in this connection be especially borne in mind. Especially is is Further.. 15 has a very happy effect. In this connec- hyoscin presents itself. . and the struggling of the patient severe. In doses of tstt or tot of a grain acts speedily and promptly in allaying excitement. tion. (veronal grs.

such as the giving of an or the administration of liquids is by the mouth. one reinforcing the other. but usually together with a small dose of morphin. without producing Its disgusting cardiac or respiratory depression. especially male patients suffering from alcoholic if it delirium. If a repetition of the dose necessary. act synergetically. In cases of great excitement a dram may be adminit istered with lasts prompt effect. and t-he slightest this. only a small dose of each being necessary. certainly within ten or fifteen minutes. too. free manipulation. the amount of the scopolamin should be reduced to 2^7 of a grain. The two drugs. now be given with ease. scopolamin and morphin. In considering remedies which are of value in bringing about rapid sedation we should be mindful of paraldehyd. can be induced to take the drug be suspended in whisky. Unfortunately the sleep produces only from two to three hours. Such also much more amenable enema to other procedures. however. and yet many patients. its odor and offensive taste are principal objections.422 MENTAL DISEASES rarely uses scopolamin alone. Paraldehyd. without there being any appreciable cardiac or nervous depression. For instance. is An exceedingly valuable remedy for hypodermic use It is luminal sodium. injection permit of Many patients after such a hypodermic A bath or wet pack. may prove to be a valuable adjuvant when scopolamin and morphin or other remedies have been given in small doses and have . a hypodermic injection of i^ of a grain of scopolamin with | of a grain of morphin has a prompt sedative effect. perhaps the most useful of It is is all and seems to be entirely free of objection. can which before such a hypodermic injection could only be given with the greatest a patient is difficulty. also very soluble and the ad- ministration of 3 grains usually followed in some twenty minutes by marked sedation and without any appreciable influence upon the pulse or respiration. This is a remedy which produces sleep almost immediately.

acting slowly. ministered. second. all. prolong it. there enter first. because of the more prompt and definite hypodermically. measures should. symptoms. liquid food. into the causation of confusion two factors: the toxins of the infection. lasts many months — three or four or more. is Delirium fortunately of relatively short duration. already administered. as a rule. In the treatment of confusion.TREATMENT been ineffectual in 423 sulfail producing sleep. so far as possible.) As in delirium. strophanthus. and perhaps pituitrin should be borne in mind. also. As far as possible in urgent cases these remedies. and the remedies. milk. Under such circumstances paraldehyd hastens the sleep. persistent exhaustion. if the loss of strength be great. and. beef preparations of various kinds should be administered. As we have seen. may be resorted In this connection. digitalis. for example. (or confusional insanity) differs less violent. and the method of their admin- istration. should be given should be ad- In certain cases. it occasionally happens that in the post- febrile period of one of the infectious diseases. heart tonics or stimulants to. instead of a delirium supervening. typhoid fever. of effect. is (See page 49. if there be danger of exhaustion. while the other remedies. less Confusion in the from delirium not only its acute character of rule. and. eggs. cocain. and questions as to the administration of nourishment rarely become acute. strychnin. camphor. we are to be guided by prin- . for example. the patient passes into a condition of confusion. alcohol This had best be given with nourishment. As a when once established. this confusion active in character. we must be guided by general principles. or when trional and phonal have been given. In the choice of hypnotics. If used at they should be used promptly and in sufficient dose. but it also in its duration. effect. be instituted to maintain the strength of the patient. However. nitrogtycerin. with milk.

should be used as. it is wise. This applies also to the use of tonic rule. and other food should be given in large quantities. If the means of the patient permit. to possible "rest employ massage. but we are especially confronted by the all-important fact of the long duration of the illness. at all. is or. As a medicines are required. difficulty. at least. the patient sometimes actively disturbed for many weeks or months. should be carried out. and Especially (see is then again to omit them altogether. for example. and supporting remedies. at his o^ti home or at some other suitable establish- Such a patient of will require at least two trained nurses. case this the when. Even cases of mild confusion do better when the plan of bed treat- ment is carried out. cases of confusion are quite manageable. As regards hypnotics. excitement. Food can usually be administered without much the patients also permit themselves to be handled readily. General principles and tioner. The question commitment depends entirely upon the fact whether the patient can be cared for satisfactorily and properly outside of the asylmn. especially during the period of convalescence. instituted. a good plan to change from one to the other. As far as methods" should be Full feeding. for common sense must guide the laid practi- no hard-and-fast rule can be it is down. as in neurasthenia. and bathed and it is also possible. his In any event. to place the patient in bed. As a rule. if only from time to time. Under these circumstances we should be content . Medication should be avoided only when really required.424 MENTAL DISEASES ciples similar to those just discussed in speaking of delirium. milk. when there is unusual The mere length of the duration of the affection a warning against the long-continued use of drugs. eggs. because of profound exhaustion. The entire treatment can in such case be conducted ment. as is in puerperal confusion page 328). proper arrangements should be side of made for his care out- an asylum.

offer Feeding does not usually it is much difficulty. as safe to leave the patient alone. and during this time as is much food as possible must be given. it is Two nurses. stupor may ensue during the Here.TREATMENT if. Now and then. to a greater or . Drugs are rarely necessary. often months. however. instead of the patient passing into a condition of confusion. stupor Many estab- weeks. the stupor that is. Because of the long duration of these affections. confusion and stupor. in and medical attendance outside of an asylum many The instances. serves the purpose of illustrating the basic principle^ underlying the treatment of mental and nervous disorders generally. again. one relieving the other. the commitment of the patient. 425 during critical periods. If convalescent period of the infectious diseases. In confusion and stupor the circumstances which usually obtain do not differ. from those of a case of some continued fever. he can be safely cared for in place. for the treatment essentially supporting in character. skilled the means to employ two attendants. Now and then. Massage may be used during the convalescence. so far as nursing and medical attendance are concerned. Frequently possible to administer very large amounts is of milk and raw eggs. as we have seen. feeding by means of the nasal or stomach-tube. not violent and can readily be controlled. its consideration of the treatment of delirium and con- geners. so profound as to necessitate forcible feeding. the question of commitment patient has the is one of practicability. his own home or in some other suitable of long duration. as a rule. a hours' duration is sleep of eight or nine not necessary. The not patient is. Like confusion. the expense involved by trained nursing necessitates. is A treatment is to be carried out similar to that of conis fusion. pass by before convalescence lished. the patient secures from four to six hours' sleep out of the twenty-four. are necessary. These embrace.

In addition. to which should be added milk and Bathing. between blankets. melancholia is the only one that can be managed outside of an asylum. should be practised of exercise should be and the absence Free compensated by daily massage. According to circumstances. these principles require modification according to the nature of the affection which presents itself. be tuted whenever practicable. the principles to be applied consist of exercise without the expenditure of energy. his excitement may is not be so great as to lead his insane. In other feeding. while the patient expansive and exalted. the patient should be full fed. tepid or warm. MENTAL DISEASES the simple physiologic procedures of the rest-cure. while these symptoms are present. absolute —should. daily. also e. especially in the acute affections or in the insti- beginning periods of the more prolonged disorders. raw eggs in liberal quantities. and yet.. boister- ous and loud in his conduct. Often he drinks to excess. i. . words. and is frequently guilty of erotic and immoral conduct. as a rule. friends to suspect that he He is. exhaustion factors of mental disorders. e.426 less degree. Of the manic-depressive group. of free elimination. Hypomania often presents numeris ous practical difficulties. a generous mixed diet should be instituted. is As in simple neurasthenic states. A case of typical acute mania obviThis is ously cannot be treated outside of an asylum. rest. those termed hypomania.. one of the dominant rest in bed Rest — radical. and this only when the melancholia is relatively mild in degree and under special circumstances. i. often extravagant and reckless. elimination should be encouraged by the ingestion of liquids and by maintaining a regular action of the bowels. true of the larger number of the milder cases of mania. massage and the securing As we shall see.

of the manic-depressive group of mental affections the milder forms of melancholia are the ones which are best adapted to extramural treatment. Warm bed bathing. after commitment. but during the time the patient is in bed she gets accustomed to the presence of her nurses to and some extent forms the habit of yielding to their domiis nation. and the the patient are finally convinced that their relative insane. As above stated. because they reject the proffered assistance of If both physician and nurses. thus the subsequent care and control of the case made less difficult. times they can neither be committed nor can they be successfully controlled outside of the asylum. misguided friends and others €spouse his cause. may instituted. even the amount of depression be not great. In the . and venience family much personal annoyance and incon- may be caused the physician and the members of the active in bringing about the who were commitment. too. the warm pack. as well as massive feeding. it not infrequently happens that the patient. Such patients are usually exceedingly difficult to treat. Quite often. It is usually impossible to persuade a hypomanic patient to remain in bed. however. rest methods are impracticable over very extended periods. however. in Cases of hypomania.TREATMENT the degree of lucidity of mind 427 may be so great as to lead the friends of the patient to scout the idea of insanity. delusional If the patient be and hallucinatory the case if is usually one for commit- ment. As a rule. Massive feeding of exercises a sedative influence and sometimes to a pronounced degree. for at sometimes present almost insurmountable difficulties. and commitment is agreed upon. this can be accomplished much be itself may be gained. If. especially when occurring women. friends of is the symptoms become more pronounced. takes legal steps to secure his release.

The patients are apt to be disturbed and made nervous by the handling and manipulation. exists. not usually the case with massage or other mechanical procedure. as is Even forms of lucid melancholia. is by no means an index of the degree or of the intensity of the melancholia. a tendency which in the milder more or less present in every case. in the asylum. we have seen. bathing can be instituted without this is much difficulty. No jury will hold a perfectly lucid patient. for imder such an arrangement neither continuous nor adequate supervision can be maintained. as we have learned. tection must be thrown about the it is Two nurses must always be insisted upon. Outside of the asylum walls. but occasionally a tactful and gentle nurse succeeds in getting the patient accustomed to it. and gentle bedHowever. Quite commonly rest in bed. Cases of melanchoUa are especially adapted to rest methods. though the pres- ervation of lucidity. There is one element in the treatment of melancholia that feel must make every conscientious physician his patient uneasy about —no or matter how carefully he has surrounded him by attendants ency to members of his family is —and that is the tend- suicide.42S lucid MENTAL DISEASES and mild forms of melancholia an attempt should always of the hospital. that the following routine be instituted: It is imperative begins the Nurse A . the greatest propatient. best guarded against though cannot be absolutely guarded against even there. full feeding. be made to treat the patient outside and for the special reason that such cases cannot legally be committed. where our lucid cases of melancholia must necessarily be treated. but take is important to see that the mis- not made of dividing the nurses into night and day nurse. the tendency unquestionably and this the explanation of the majority of suicides of which Self-destruction it is we read in the daily papers.

if at other times he will swallow the food automatically it be placed in his mouth. and nurse B. the plan above outlined is much better for the nurses. However. Feeding by the stomach-tube may is encounter active resistance if by the patient. A now goes ofT duty. who may firmly clinch his teeth. A far readier and . each secures a good sleep every other night and has abundant time to sleep the next morning after a night of duty. or. Finally.TREATMENT 429 she then takes the day by first having her own breakfast. by a tube introduced through the nose. breakfast tray to the patient's room. off duty. who has been Nurse with the patient during the night. In this way com- pletely "covered" for every minute of the twenty-four hours. and then takes the dinner tray to the nurse patient's room. better. The ordinary upon other division of the nurses into day nurse and night nurse of necessity permits of a hiatus at meal times as well as occasions. then takes the supper tray to the patient and goes on duty for the night. At six or six thirty nurse A has her supper. A and later gives the bed-bath and carries out instituted. in the consideration of melancholia. the latter bite the are forcibly separated there danger that he may tube or the fingers of the physician. Sometimes it is possible to persuade the patient to eat. may be accomplished by a tube introduced into the stomach by the mouth. now and This then we are obliged to resort to forcible feeding. she is The next morning the patient is reheved by nurse B. such other treatment as nurse may have been At noon B has her dinner. goes feeds the patient. Not that infrequently persuasion and the is cup and spoon are all necessary. the pa- As pointed out tient usually suffers from a loss of appetite which is sometimes very pronounced and not infrequently leads to a refusal of food. In long-continued cases the strain is thus much better borne.

430 MENTAL DISEASES satisfactory route is much more At the of first offered by way of the nose. as well as in stuporous states. While passing the tube. the larynx is sometimes much obtunded. which of course liquid in form. is then gently poured into the funnel. warmed and should be gently introduced in a direction If it parallel to the floor of the nose. In melan- cholia. When the requisite It is amount has been introduced the tube while this is is withdrawn. As a rule. the physician should have the assistance one or perhaps two nurses. The nurses should prevent any untoThe ward movement of the head or any attempt on the part of the nostrils should first patient to seize the tube. the tube should be into the other side. be verified by gently percussing the stomach while the operator holds the free or funnel-shaped end of the tube near his The position of the tube having been deis termined. is be found that resistance encountered. so it that fluid or even the tube itself may enter without exciting a paroxysm of coughing or immediate evi- . be cleaned with a little absorbent cotton. and the fact that the stomach really in may ear. as is by this expedient the If tube much less likely to enter the larynx. and then the nasal tube. the food. the patient be permitted to throw the head back- may pass around the soft palate and enter the mouth. the tube the lips. slightly oiled. feeding. important being done to compress the tube so that no liquid may escape from it as its opening passes the larynx. It should withdrawn and introduced be gently pushed backward. where it may curl upon itself or be protruded between ward. and will be found to readily glide along the posterior wall of the pharynx into the esophagus and thence into the stomach. it is wise to gently depress the chin. little or no difficulty is encountered in it is properly introducing the tube. lie The patient may be seated in a chair or upon his bed. due possibly to a markedly deflected septum or other cause.

for cases. under such circumstances. It From need time to time. and repetition is performed with ease and certainty. and. time and the method may be kept up months. for improves rapidly. or soup may be substituted. The According to judgment. if hardly be added that. though an insufficient amount of food. as a rule. the procedure is attended by no its danger. and it is good practice. milk had escaped into the larynx in apparently considerable amount. It is perfectly possible for a patient in state of good nutrition to go without food for a very long time. if he has lost it is not wise to wait until he refuses food absolutely. necessary. insufficient amount of food. medicines may be admin- istered with the feeding. The patient's nutrition. for years. should of course be under close observation. orange juice should be given.TREATMENT dences of strangulation. is As a however. no resistance on the part The question How long If is it proper to wait before in- stituting forcible feeding? the patient has for a long time been taking a grossly weight decidedly. a patient whom in consultation. the patient subsequently died of gangrene of the rule. At times a broth also. did a serious accident occur. daily. should contain milk and raw eggs. but to resort to forcible feeding before emaciation becomes serious or pronounced. If the patient has been taking some. . arises. feeding should take place twice it to a quart. to feed after waiting three days. the writer saw 431 In but a single case. safe to wait a week or even longer. say a pint or less. one can wait with safety two or three days. but it is unnecessary to run any risk. A a on patient. The amount of the feeding should be small at first. lungs. later this may be increased to a pint and a half. in given a long — for weeks. and finally accompanied by a lessened and of the patient. the average. it is If he is well nourished and is still drinking water. or even more.

amount of food should be small and relatively simple. gentle exercise. In such case the patient rises late. in cases in which both the stomach and the salt bowel cease to be retentive. Occasionally. etc. retires early at night. and in such case Occasionally vomiting follows it is also wise to wash out the stomach and to wait a suitable the interval. a half -hour later the enema may be given.. The bowel should first be washed out and then quieted by an opium suppository. a little peptonized milk and lime-water. bath. quently "partial" rest methods are entirely adequate. fluid and the action stronger. and He has a daily sponge or brief immersion full feeding. These may consist of peptonized milk. and the physician should be prepared to meet them. Commonly Quite fre- simple rest methods and watchful care suffice. peptonized minced beef. the vessels become heart's The filled. the feeding. a crisis occasionally be bridged over by this means when weakness and emaciation have become marked. may also be employed and often with advantage. though than hypodermoclysis. a hypodermoclysis of solution common may be resorted to with advantage.432 MENTAL DISEASES instituting artificial feeding it is Sometimes before a good plan to wash out the stomach. However. Especially may is. or perhaps albumin- water. say twice daily. they every now and then present themselves. and . It is naturally less efficacious unusual for cases of melancholia of such a character as to permit of extramural care to present the serious difficulties met with more commonly in the graver asylum cases. lies down in the middle of the day. rapidly absorbed. eggs. The procedure may Enteroclysis it is of course be repeated. in the next feeding e. massage. g. A very unsatisfactory procedure is that of nutritive enemata. as a rule.

too. Cases hallucinatory paranoia of average course and severity. sleep better. twenty pounds in a month. recourse may be had to efforts at re-education and retraining. he is and pay attention to his delusive ideas. and the question arises as to what had best be done. of fact. a wise plan to submit the patient to a radical course of rest treatment and to make every possible effort to force up the nutrition to the highest possible level. is a sufficiently strong indication of the wisdom of such a course. he will eat better. the As a matter body weight is sometimes increased surprisingly under these circumstances. Usually the friends of the patient stoutly times. To this we of will presently recur. especially of abdominal tuberculosis. however. However. when the evidences of gross impairment of nutrition have been in a measure successfully combated. as as much. at it is such that doubtful whether he can be held by the asylum authorities. should always be warned that paranoia. now and then we meet with mild and comparatively harmless cases. less the patient. rise to usually may come when the The patients that give the greatest difficulty are cases of paranoia simplex 28 . Unfortunately. The best plan is to secure If some simple and congenial employment for occupied and kept busy. an appropriate occupation or various other psychotherapeutic procedures subject may be resorted to. require asylum commitment. no it is matter how mild. for example. rarely remains stationary. The friends. here the ordinary physiologic methods applicable to other cases of mental disease are of httle use.— TREATMENT 433 is The treatment of cases of dementia praecox likewise to be it based upon general principles. is In a large number of cases. the patient's lucidity is resist commitment. that a progressive affection. Later. and that the time patient will be dangerous and violent. The fact that so many- cases die of tuberculosis. as a matter of course.

relatives. latter should. whenever the patient's be instituted in the most radical manfull feeding. the patients from an inherent neuropathy complicated by a nervous It exhaustion more or less profound. The nurse should The on a cot in the patient's room. 165. and massage should be carried out elaborately and systematically.) In the neurasthenic-neuropathic insanities. gentle bathing. and physicians endless trouble. to say. nor of is the patient to leave the bed except for the purpose emptying the bowels or the bladder. The patient instructed to quietly. mental and all . The rest should is be made lie as nearly absolute as possible. The patient should rest. not only have physical above all. as we have learned. the patient counsel. the patient should be submitted sleep an absolute isolation. rest. may employ and give friends. not to sit up. that commitment suffer is justified. but. impera- male patient should have a male usually necessary to give close attention to the carrying lest out of the details the purpose of the treatment be defeated by some apparently trifling neglect. ever. The it. (See p. The patient should be placed in bed. if committed. and may be a source others. should be of the tive that a It is nurse. seems unnecessary to field. may suppress his delusions. the per- the non-hallucinatory form. of serious annoyance and even danger to and yet. point out that here. except for the special purpose of taking food. As has been shown. secutory delusions may be clearly defined and unmistakable. very rarely. circumstances permit ner. we have a group whom must if be a treated outside of the asylums. and no one should have access to the room save the nurse and the physician. above to all.434 MENTAL DISEASES Here. but. nurse. more than in any other are rest methods indicated. it is unnecessary It is same sex as the patient. of patients all of it is the psychas- thenias.

It is for this reason that isolation insisted upon. wheat bread is in any quantity. Sometimes it is wise to begin with milk alone. and salts. addi- tion of a httle table-salt makes the milk what is Finally. It is wise to begin with a moderate amount of food only. 8. but diet should be approached gradually. that the tissues require —proteins. squash. At times the palatable. Sometimes this objection is is based upon an actual idiosyncrasy. as a rule.— TREATMENT sources of mental and emotional excitement 435 must be must be rigidly avoided. stewed celery. between meals. or Apollinaris. the milk may be predigested. of course. string-beans. such as pancreatin . Seltzer. and just before the hour in However. At alka- times the difficulty water. vegetable acids. may be added also until a full diet reached. vegetables —spinach. is and other vegetables Eggs may. most patients some solid food can be given in the beginning. or artificial plain soda-water. The milk should be are taken six increased slowly until 10. one all capable of furnishing fats. often a better plan. giving this in exceedingly moderate quantities —4 to 6 ounces at meal-times. the white meats should. or. still overcome by effervescing. The neuras- pre-eminently in need of a mixed diet. Not infrequently the patient objects to the milk. however. as should also thenic. this full carbohydrates. for sleep. In such instances so that milk digested with great difficulty. Potatoes should for a long time be excluded. The and succulent later peas. ferred. we may make line a trial of is various forms of modified milk. This necessitates the exclusion of relatives and friends all as well as the suspension of correspondence. 12 or more ounces times daily. be given. the addition of some or such as Vichy. a small quantity of some digestive powder. be pre- As regards meats. The diet is that applicable to exhausted states generally.

At first it is wise to begin with one egg between meals. a patient has taken a large number eggs. may be added before the latter is is taken. is also of great advantage. fails. so that in number are taken. than that seen in jaundice. and should be given in increasing number daily. two —and many thus the number of raw eggs instances quite a large is increased. however.436 MENTAL DISEASES to the cold milk just if it and sodium bicarbonate. too. as circumstances permit. who day. and when to milk. it In other cases. frequently well digested it is Occasionally necessary abandon milk and under such circumstances we may resort to follows: in such egg feeding. or even large if more eggs borne. in a Usually these quantities are well Exof ceptionally. lemon-juice. answer as a substitute for milk for any lengthy period. rather. three. The tinge. however. the limit reached at eight or ten eggs. egg without salt. altogether. whey can be employed with benefit. however. there is no discoloration of the conjunctivae. or other attempt at flavoring. patient is then directed to swallow the egg whole and with a single It is best to administer the effort. eighteen. especially there marked consti- pation. as it suggests an attack of jaundice. or four. Buttermilk. the number being increased to two. The coloring of the skin sometimes alarms the patient. many as a dozen. does not. the skin acquires a yellowish tinge. However. Eggs are best given raw. Later. take as There are patients. Kumyss or. even modified. if can be obtained. a raw egg is given after each meal is —sometimes As a rule. is of a brighter yellow The staining of the skin can be made to disappear by simply withdrawing the yolk and restricting the egg feeding to the whites . The procedure The is as A a raw egg is carefully opened and dropped into a cup is way that the yolk not broken. and even more. imitation is kumyss is of much more value than whey.

tinctly less 437 In a few days the coloring becomes disfinally fades altogether. be taken under massive feeding to keep the bowels open. is sometimes astonishingly If attended by a rapid increase in weight. latter The conversafirst tions between the and the patient are at gen- . the muscles cold. of course. in weight. no untoward consequences are observed. of the is stomach or of the abdomen results. It is noted that the patient increases firm. The patient gradually passes into a condition of placidity and contentment. No undue distention and. by. Finally.TREATMENT of the eggs only. may havoc by the gossip and injudicious coram unications which she If may bring into the room. seuse into the The introduction of a strange maspatient. Great care should. proper precautions are taken. too. has learned to all know little personal peculiarities of her patient. gastric or intestinal. various changes are noted. no digestive disturbances. the details of the treatment be properly carried out. the physician and As the days and weeks pass becoming more and his patient are more the closely acquainted. room very frequently disturbs the The create masseuse. that the case progresses favorably. of course. accompany this surcharge of the digestive tract. it is pronounced and of food The quantity and which possible to administer to is neurasthenic patients at rest in bed large. to see that the skin bathing. provided. if she be not a very tactful person. of which she faithfully communicates to the physician. Nervousness and restlessness give way to quiet and an increasing sense of physical well-being. the extremities cease to become be and the patient begins to lose her pallor. when the amount again reduced to normal. The nurse. and to see that the massage is is kept active by given thoroughly. it is important to add that the massage had best be given by the nurse.

Especially is this the we are at present considerfre- It is wise for the physician will not to be in a hurry.438 MENTAL DISEASES time passes. but. the memories of sexual experiences are not so hidden and obscure as to necessitate the elaborate and tedious methods followed by Freud and his rest followers. and at times speaks of some one matter. As a no rule. as the patient reaUze that a complete understanding has not yet been estabhshed between them. the increasing confidence of the patient. too. be it remembered. As a the conversation proves to be a of various long one. talk with you. the phobias. that has been worrying and it is In the experience of the writer infrequent for this fact to deal this is every with the sexual life of the patient. who mind in turn in- forms the doctor. the patient thoroughly relieves her matters. the and the general body surface are . unloads her worries and cares. rule. lead. a physician experiences in treatment difficulty. by of simple and direct methods. fact. and his experience has been the same with both male and female patients. During is all of this time. to gradual disappearance of the special fears. perhaps an intimate personal distressing her. she I break down the barrier herself and say." or must some day have a longer may communicate her desire to the nurse. The opportunities offered by the daily visits of the physician. case in the form of mental disorder ing. in determining the real importance. sexual or factors other. the heart's no longer rapid or disturbed. as relief which a the free discussion of a rule. the bodily condition undergoing marked improverhent. tachycardia no longer hands and feet occurs. from which she suffers. though now and then the case. quently the patient "Doctor. both the physician and eral in character. speaks to the doctor of her personal affairs. large amounts action is of food are being digested and assimilated. Further. and her tendency to seek the her case affords.

of kinds are ex- field of Buoyancy. The symptoms due to defective inhibition. Chronic indecision in and aboulia. more especially of thyroid inadequacy. as a rule. normal in amount and and the atti- mind ceases to be introspective. crowded from the until morbid ideas consciousness. the patient affection has not been present long. connection with these symptoms we must bear in mind the not infrequent presence of disturbances of the internal secretions. it is true. chronic indecision and aboulia. and the conse- quent benefit to be derived from the administration of thyroid extract. a desire. if the peculiar gestures. case depends upon two the degree of neuropathy present. is . not. though in frequently necessary to maintain suggestion and retraining for some time after the bed-period of treatment has been concluded. spontaneity. tics. but this extends as a rule over a number of months only. Time is required. disappear comparatively readily. second. pectancy. "defensive" movements. if However. and the like phenomena are much less promising. tude of sleep is 439 refreshing. their case The phobias it is also eventually disappear. under the powerful stimulus of the physical will. invigoration and the added stimulus of the physician's lessen and disappear. three or four. and finally a demand. as in psychanalysis. the special length of time during which the symptoms present have persisted. little Soon a sense of well- being becomes established. for action mark the mind transformation. and. self-assertion. coprolalia. over two and three years.TREATMENT warm. Suggestion by the physician as to the disapwilling pearance of the phobia now grafts itself upon the mind of the patient with tenacious force. which by little becomes more all and more pronomiced. offers During all of this period the patient's a fertile field for psycho- therapeutics. The degree largely of success achieved in a given factors: first.

seen. Even then accomplished by rest. The character of very important. I think. No one questions the fact that full recital by the patient the to her physician of her details is symptoms relief. more durable. the latter should consist of slowly carried out movements of precision. great success in long-standing cases may attend much is now and be the followed exercise our efforts. full The their relief which persons experience from a account of symptoms and the is inevitable concomitant emotional disof course. the above procedure —the in Weir Mitchell combined with psychotherapy a —yields much the results incomparably greater. in which the results achieved by these means are alike successful and often brilliant .440 still MENTAL DISEASES young. admit its truth. so great and so insistent the sufferer voluntarily statements which he knows may lead to disgrace. prove to be resistant and inveterate. severe and long established especially typical tic convulsif. in a more marked degree and yet typically. probably because of the of the neuropathy. especially if this by is persistent exer- cise. more pronounced character Compared with rest treatment of psychanalysis. imprison- ment. this and a sustained action Accompanied by encourleads agement and suggestion. method not infrequently However. Such movements require mental concentration of the will. to a gratifying result. Rest and the psychotherapeutic procedures above detailed are applicable of course also to hysteria. tics. and of all of associated a source of Every neurologist of experience will. and shorter period of time. in the for relief making of confessions. and at times even to death. which should gradually be made more complicated and difficult. demand makes under these circumstances that as is well known. at times the is. charge.

because of the possible danger of an attack of delirium. according to the method already described. but that "partial Space it rest" often suffices. praecox is that their usefulness in dementia is much more limited equally evident. the pa- tient be placed in bed and have adequate supervision by nurses. though. and perhaps massage. mitted to rest treatment. it may be effect wiser. and massage can be thoroughly carried out. The cially general principles of the rest treatment are also espe(See p. in dementia praecox. together with bathing. to of make the withdrawal gradual. with liberal feeding. as well as in other mental affections. That the psychotherapeutic methods above outlined should be applied. by methods the time it is fre- quently counted by weeks. morphin or cocain can be withdrawn at the will of the physician. Usually alcohol can be withdrawn at once. and a withdrawal as rapid as consistent with safety should be instituted. patient show the if the marked effects of a recent excess. bed- bathing. the moral a too prolonged withdrawal is bad. should be added that methods are not always necessary. in so far as they are indicated. They are applicable in melancholia. is However. (See p. the same time. .TREATMENT and remarkable. 212.) By this means At access to drugs and stimulants can be full rest entirely prevented. it is in every case sub- not necessary to add.) If appHcable to the intoxications. rising late full and lying down during a feeding. implies an increased amount of rest secured by retiring early. full rest Finally. An ideal plan of treating a drug-habit is to institute absolute isolation with two trained nurses. gentle exercise. part of the day. six 441 results in Freud speaks of achieving rest from months to three years. treatment. 428. the alcohol. will not permit of a consideration of partial rest in detail. intervals Suitable occupation in the must not be forgotten.

the patient has been in the habit of receiving hypodermic injections. 2^-Q As the dose of the morphin is diminished. My practice is almost invariably that of very gradual withdrawal. more scopolamin greatly relieve the suffering of the patient and keep him much quieter than he would otherwise course. intensely distrustful. much fully wiser to make the with- drawal gradual.442 MENTAL DISEASES it is In the case of morphin. and proper diet soon becomes pronounced. especially. so slow at first The withdrawal should be is that the diminution of the dose later practically If imperceptible. if the patient learns. on the reduction may be more rapid. especially as the physical comfort resulting from the bathing. hyoscin or scopolamin should be added to the hyiDodermic injection. of no danger of the formation of a hyoscin or scopolamin . confidence sooner or later asserts itself. small doses of atropin sulphate. first in small and then in larger doses. It is my practice not to begin withdrawal of is the drug until rest-treatment under way. the patient of is. after his first still few days of rest and isolation. and say if the skin be very moist. massage. I Further. There can be no question that hyoscin and. know no class of patients with more more difficult to establish friendly relations or in difficult to inspire confidence. it is my plan not only to reduce the dose gradually in the manner indicated. There is. that is he is receiving his hypodermic injections. One must remember that the morphin habitue labors under an excessive fear lest the drug be withdrawn too soon. if As a rule. say -^ of a grain. of a grain. Besides. be. sudden withdrawal always implies a period of frightful physical and mental suffering. or that he still being allowed his usual quantity of laudanum or opium. as a rule. the atropin may be discontinued the scopolamin be given. whom whom it is it is However. but also to begin adding to the in- jection small doses of strychnin sulphate.

but they can be controlled. dyspnea. besides. with excessive prostration. and finally delirious. practical)le to withdraw the true that insomnia. in fact. and collapse are liable to occur. it is expedient to withdraw the cocain at once. signs of collapse. and. In other cases. the alcohol rapidly. is 443 in complete control of the The physician should be especially cautioned not to make use of cocain during the withdrawal. and the . but also to prevent the onset of serious symptoms. the writer practices immediate withis drawal. perience. palpitation. or. Every now and then. Many cocainists spontaneously after the usually a good plan to give mere withdrawal moderate doses of the drug. but of trional or sulphonal at night. may set in. In the early morning coffee may be given to lessen the depression. sweating. and dyspnea. the patient becoming hallucinatory. In cases in which the alcohol habit is also present. again. confusional insanity mental symptoms resembling those of make their appearance. The morphin should. The same marks apply also to alcohol. the experience of Norris entirely the author's ex- The bromids are very efficacious in combating the sleep it is symptoms.TREATMENT habit.) delusional. diarrhea. (See page 231. the cocain may usually be withdrawn at once. however. As regards drug at once. it is. if the drug be abruptly withdrawn. at later acquire any time. My reason for withdrawing the morphin in the gradual maimer above described is not only to diminish the sufferings of the patient. cardiac weakness. It is as a rule. a large number come under our care for the morphin re- habit have already acquired the cocain habit. cocain. Further. In cases in which morphinism and cocainism co-exist. be withdrawn in the gradual manner already described. inasmuch as the patient may sooner or the cocain habit. much more readily As a rule. the physician situation. with of patients that disastrous results.

into that of simple morphinism. morphin The morphin distinctly overshadows it the other drugs.) Surgical procedures have. is unfortunate. be carried out in connection with the treatment of paresis. the e. like. the treatment of the itself. Usually only when the patient has passed fully beyond the legal boundary of It sanity that he can be properly committed and restrained. habit" resolves sooner or later. such as tumor. (See p. and psycho- Elaborate rest methods are. even when the patient has the necessary means. abscess and the surgery can play no role. fortunately the law does not as yet Un- make possible an adequate restraint of inebriates. done by the way of occupation. had best be continued it in full doses for a number of days. that we must frequently wait until crass insanity supervenes before effective treatment can be instituted. In microcephaly . thirty days. focal epilepsy. ''triple In other words. Later may itself be gradually diminished. as a rule. mitment only holds a time which is for a very limited period. so that.4:44 MENTAL DISEASES slowly. other things equal. of course. only a small role in mental diseases. nothing can be accomplished by the most elaborate care unless he is entirely willing. moral therapy need hardly be emphasized. out of the question with the larger number because of the expense entailed. as may readily be inferred. Rest methods should also. Their thorough appHcation plays a large part in the results achieved by salvarsan and other therapy. Even when the com- patient is willing to commit himself to an institution. inebriates should be under supervision for a very long of course imperative. Aside from the rare cases in which there is gross disease.. g. and. it is of course utterly inadequate. 309. That period is and that everything should be influence. to say the least.

the least disturbed and the most . experience militates against interfering with a preg- nancy when during their appearance. as in other cases. its course mental symptoms have made tendency is As we have seen. Again. such an interpretation is in keeping with the view of the toxic arrest nature of the psychoses. the problems presented are ent. differ- However. of progress Sometimes remissions and after severe have been noted trauma or severe surgical shock. on the whole. at the same time. and pregnancy is this course is not changed when the' terminated by miscarriage either induced or spontaneous. Less frequently similar results are obIt served after an abscess with febrile reaction. would seem as though we had here to do with the formation of antibodies. in mental cases in the course of which there is an attack of some acute febrile infection. in the main very We must remember that cases suitable for extramural as regards the care are. the possibilities most favorable. Pelvic operations in the insane should be based. INTRAMURAL TREATMENT The general principles of treatment applicable to extrafor mural cases are of course the same intramural cases. They are. such as typhoid fever or erysipelas. Occasionally there is a remarkable cessation of progress.TREATMENT 445 the operation of craniectomy has deservedly been abandoned. and at times a recovery. both of therapeutics and the likelihood of recovery. upon surgical indications only. This is equally true of operations involving other portions of the organism. experience has shown that mental disease uninfluenced by them. This is also the case with operations upon the is pelvic organs. the to the ter- persistence of the mental symptoms after pregnancy has minated normally.

and the like. always has the resource of com- mitment. more individuaL therefore. The modern less closely hospital for the insane approximates more or is the ordinary hospital. — is still to a large extent imprac- It necessitates a corps of trained nurses.— 446 MENTAL DISEASES also is amenable to treatment. General hospital care. the physician. these important facts must be borne in mind. and also that great nmnber whose means do not permit is of extra- mural care. the treatment If. from the struggle for existence. it is being introduced to an increasing is extent. if an ideal plan of handling a recent admission and especially the patient be in a first attack. Of necessity. from the burden of life. found everywhere. it be maintained that the results of extramural treatment are more favorable than those of the institutional. bed-treatment based upon rest principles ticable. there are many patients who from privation. e. and de- mands an amount of individual attention . stupors. which it is as yet impossible for most hospitals to give of cases. Bed-treatment as such i. as in the dementias. usually of two. provision made for cases confined to bed either by reason of mental or physical incapacity. from the absence of physiological living or from worries and anxieties often too hard to bear. have broken down. present striking as well. and important physical features Other things equal. at least. is to place the patient in bed . In the institutions are naturally found the great mass of disturbed cases. a care which always expensive. catatonias. of course. the chronic demented and hopeless forms. Among the recent hospital admissions. We should remember that even isolation in a private room necessitates the employment of a special nurse. finding after a trial that the proper care of a patient is not practicable outside.. and who in addition to their mental symptoms. indeed. to large numbers However. Finally.

a study of the circulatory apparatus. of the disorders of nutrition and metabolism. per- haps merely a tachycardia. the history of a late oncoming and irregular menstruation never properly established. they are Such evidences are rarely pronounced. of the Again. are frequently present. a delayed or imperfect puberty. and of the digestive tract.TREATMENT 447 and. degree of infiltration of the skin and dryness only exceptionally may we may note anything approaching a typical of secretion present. commonly quite but nevertheless present. Especially important to note the history of the patient in regard to the development of the sex glands. Not only should and this include a visceral examination. significance. hypothyroidism may express itself by a very moderate of the surface. of the blood secretions. myxedema. secondly. to examine him exhaustively from the standpoint of internal medicine. The same toms holds true of course for hyperthyroidism. that the presence of this hormone evokes the production of defensive ferments which in turn are injurious to the cortex latter. the symp- may not be — usually is it are not — sufficiently pronounced to present an exophthalmus or other striking feature. and bring about the destruction. abnormalities in the sexual development which . just as is done in the wards of a general hospital. ready sweating or ready exhaustion. For instance. to the sex glands as playing an important role endogenous mental deterioration. but especially should we seek for evidences of These. as we have seen in (p. but. as is disorders of the internal secretions. emaciation. Thus. of the possible infections. and what not. is of great The researches of Fauser and others point. slight. especially in dementia praecox. though be of profound clinical significance. well known. Here studies by Fauser and others have led to the conabnormal hormone is clusion that an thrown into the blood by the sex glands. obesity. indeed. the lysis. 131). and yet the disorder moderate in degree.

may point in given instances to the and in other instances to the pineal gland. while others again take to their beds spontaneously. and such factors must of necessity influence the result. when appUcable the indications clear. be retarded and incomplete or on the other precocious or excessive. rest are its However. but the latter are unquestionably to be found Naturally. we find that . many patients are kept in bed with difficulty. to place recent cases in All things considered. that these measures are appUcable only to a limited number of the insane. while the glands of internal secretion also have lessened demands made upon fact assumes a them. for radical very Rest is an expedient of great power. inadequate. The upon the neuromuscular apparatus and upon the heart is and blood-vessels to a great extent removed. especially applicable and most readily carried out in the milder and less disturbed cases and are here productive of the most striking results. pituitary gland Finally. of course. the rest is among the cases of recent origin. When we turn to the question of full feeding. the consumption of tissue greatly diminished and a lessened amount strain of waste material is thrown into the circulation. recent cases frequently present the marked evidences of nervous exhaustion or of some other general im- pairment of nutrition. it would seem wise less radical bed and to institute a more or course of rest and I full feeding. mixed clinical pictures are often presented. The last-mentioned recall marked importance when we how frequently in the insane these glands are deficient. on the one hand. Again. perhaps the entire chain of glands defective or aberrant in development. or aberrant. am aware. which justify the inference that a number of the glands of internal secretion is are disturbed. too.448 MENTAL DISEASES may. In addition. is By means the expenditure of energy is reduced to a minimum.

but this role equally clear in the autotoxic states. and hypernu- trition not only adds to the substance of the body but also In excessive feeding. in accordance with this truth. peptones. Finally. play a not only one of most important role in the formation of antibodies. is The problem 29 that confronts us in insanity exhaustion but also of intoxication. and even the erythrocytes and the blood-plaques play a role. In the toxic insanities. gain access not only to the portal circulation but even pass through the liver. the latter It assumes the all function of completing the digestion. instance. for these are in a sense self-infected cases and the problem in no- wise differs. In massive egg feeding. as we know. Full feeding means hypernutrition. not only the ferment-producing power of the blood stimulated in hyperfeeding. Abderhalden found. but the lipoid substances also are largely increased in amount. Once in the blood. in and it would appear that no tissue is this function better preserved than in the blood.TREATMENT this is as imperative here as in simple 449 and uncomplicated neuras- thenic states. and under these circum- . also retain the primitive function of digestion. that ferments intestinal tract make is their appearance in the blood when the overfilled with protein. unchanged protein enters the blood and can be demonstrated by the it pres- ence of ferments. is from that offered by tuberculosis. for instance. and lipoids. protein substances which have been only partially reduced. those resulting from poisons introduced from without and those resulting from the infections. the role of overfeeding is is thus made clear. the cells of the would appear that body in addition to the special function imposed upon them by the special organs or tissues of which they are component parts. for profoundly influences metabolism. or carbo- hydrates. Here the various leukocytes. for instance. lates thus the In exhausted and enfeebled states stimu- formation of antibodies. the plasma.

liver. that the intoxications which result from them are of short duration. usually only is many months. the defensive action of the liver and other glands. €. Thus. when prolonged insanities ensue after acute infections. an auto-intoxication secondary to the original infection. but also of those in which the poisoning is primarily of extraneous origin. is. by the gradual formation effort at of anti- bodies. but these are not the poisons nor the processes which usually deal in concern us in insanity. the poisons at work have their origin in a secondary disturbance of function of the of the kidney. by the continued immunization. and which consequently influence the metaboUsm of the organism for long periods of time. In such instances the organism successfully resists and disposes of the poisons speedily and promptly. Not such as the manic- this true of the poisons present in mental diseases which are essentially neuropathic and hereditar}'-. depressive group and the group of dementia prsecox and paranoia. Consequently. as cance and importance. are variously changed chemically. a special signifi- stances hypernutrition assumes.450 MENTAL DISEASES we have seen. is receiving In a patient who is resting and who. those which are not destroyed by the various glands and other defensive structures. The poisons with which we mental diseases are mainly those of long tenure.. whatever the character or the source of the intoxication. of the adrenals. The intoxications to which the organ- ism is subject may be roughly divided into two groups. However. and is of other glands and tissues. Some poisons exercise but a short tenure. nature is forced to fight the battle i. Such poisons are successively submit- ted to the defensive action of the gastro-intestinal juices. and finally destroyed or eliminated. of the thyroid. clinical The fact of such involvement based on indisputable and pathological evidence. a disorder of metab- oUsm ensues which constitutes of itself an auto-intoxication. in addition. .

There is is one important fact. important. much more than this. In addition to hyperfeeding. in its more than however. and massage there remains It is another powerful expedient. This was. way local nutrition especially Ordinarily we think of massage only as benefiting the circulation. doubtless during the process of kneading. attended way it also stimulates metabolism and at times It is even by a slight increase in the intake of oxygen. not my intention to dwell upon the familiar It does really fact that bathing this. to emphasize the fact that in patients undergoing rest treatment bathing should not be vigorous. as increasing the flow of blood to the part rubbed. the liquid por- tions of the blood are forced into the tissues. in others it or. in the it is average case best limited to gentle sponge-bathing in bed between blankets. all of each individual depends upon the character and peculiarities case. John K. It is obvious that during mas- sage. however. Many years ago in making a blood count of a specimen of blood taken from a limb before massage and comparing this wuth the blood count of a specimen taken immediately after massage. and one that emphasizes the great value of massage. passive exercises better still. exercises with resistance can be instituted. of course. . The liquids of the cells is blood are thus brought into actual contact with the and it is extremely probable that in this stimulated. is clearly inappHcable.TREATMENT large 451 for the I shall amounts of nourishment. Individual cases permit of the expedient in varying degrees. but evidently it accomplishes rest. is stimulates elimination. in regard to massage it is that not generally' known. nameh% that of bathing. not dwell upon the applicability of this procedure in the insane. Dr. In some. however. we must compensate absence of exercise whenever practicable by massage. indeed. a relative increase only. Mitchell noted a largely increased percentage of red blood-cells.

of coUrse. the freedom of restraint offered by the absence of clothhalf floats in the water. upon the gain in weight. exercise. blood-pressure. to acute mania. employmeht may gradually be serious instituted. probably there is also a corresponding lessening of tension and fulness in the cerebral vessels. be restless in the If the patient continues to struggle or to . delirium tremens. lessens is it ing and the fact that the the tendency to resistance. The warm water has a calmative and body fluence. should be carried out for weeks and months goes. respiration. The procedure is especially adapted to active deliria. and upon other factors.. and bodily temperature reveal no changes of moment. several weeks. warm immersion bath The patient is placed in a bath of a temperature in the it and allowed to remain bath for one or two hours. or. reflex Resistance to a large extent and is stimulated by that which encounters. for several days. practised extensively in especially Here an expedient Germany for the last fifteen j^ears. How long they should be employed depends of course upon each individual case. when the latter has apparently reached the highest level possible under rest measures. upon the progress made. or better. The pulse-rate. without saying. said that It may be safely when the level of the general health of the patient has been distinctly raised. has proved to be wonderfully efficacious. diversion. The patient who has been noisy and struggling soon becomes relaxing in- quieted. to achieve a maximum result. is The fall bath also greatly favors eUmination. e. g. of 95° F. be. may months. by Kraepelin. to the excited periods of dementia prsBcox. and to other acute disturbances. This consists in the use of the prolonged (Dauerbad). is The most problem in asylums for the insane always that presented by the disturbed cases. due to dilatation of There a rapid of the peripheral vessels.452 MENTAL DISEASES rest That and hyperfeeding.

patient The may go to sleep in the bath or upon being re- moved to his bed. The nourishment should. is also true some cases of disturbed catatonia. of course. expensive. according to circumstances. he may be permitted to remain in the bath. the presence of a number of well- trained attendants. while violent also greatly diminishes chances of injury in cases. as a rule. gr. hypodermically be- bath. and of this. Luminal sodium hypodermically would here seem to be especially applicable. fore the or j^-^. Bed-sores are prevented. seems it to be ideal. The bed desire for food is is much increased. curred. Sooner or is later. but not longer than two hours.TREATMENT bath. latter. Kraepelin does not force him to remain in it. is In the he believes that the warm wet pack sometimes more practicable. case. gets used to the procedure difficulty. 453 but renews the patient the attempt after an interval. and can certainly do no the harm. the patient just as in a fed very readily. be given at regular intervals and if neces- sary night and day. the advantages of this in filthy cases needs no com- ment. if they have already octhe occurrence of clean. | or j. The installation of the permanent warm baths also. -gTo together with scopolamin. They require. Finally. for an indefinite period. gr. according to Kraepelin. is. Cases of agitated melancholia are not adapted to this treat- ment. menstruation no obstacle to the treatment. The plan practised by Pfisterer of giving morphin. but the advantages of the treatment are . and. he thinks. The patient should be allowed to remain in the pack until free sweating results. As indicated above. are kept ideally offers or. The bowel movements and off urine are disdischarg- charged directly into the water and carried by the ing pipe. and placed in the bath without A dose of sulphonal may be given some hours before or a hypodermic injection of hyoscin shortly before.

the latter being given to combat the exhaustion. the employment of hypodermoclysis is in certain stuporous cases. The fact that the patient becomes quiet and remains quiet without the use of drugs. to say the least. however. Hogan^ The proporgm. the intravenous injection may be especially the acidosis medicated. The prolonged immersion well borne. 8. is a very great gain. and can be nursed without struggling is. The epithelium may become somewhat swollen and be here and there some irritation of the are minor troubles there may hair-follicles. that he eats. been carried out by direct marked success. tions used ^ . sodium followed such an injection immediately by a solution of glucose. It has I believe. method is in such cases with very satisfactory risk The procedure unattended by and should. which sometimes followed by striking results. . Hypodermoclysis obviously inapplicable it is. con- There is one procedure. which deserves I believe in especial mention and which I refer to given instances to be of great value. December 16th. A more method is is the free intravenous injection of normal salt solution. 1826. be more frequently practised than Pilcz for years with it is.8 gm. Here sodium bicarbonate and sodium bromid may salt solution. 1916.•454 MENTAL DISEASES exceedingly great. sleeps. be added to the and in this way both and the edema of the brain tissue may be counteracted. Here it unquestionably stimulates elimination. however. sodium chlorid. of Vienna. In given instances.4 See Journal of American Medical Association. as ' practised abroad. but these and are readily treated. to the stupor of catatonia or the stupor of melancholia. by Hogan are 5. undoubtedly apphcable to the stupor of infection and exhaustion. is more especially by Pilcz. I have on a number ing this of occasions had the opportunity of employeffect. call for detailed Other methods of hydrotherapy do not sideration. p. as in alcoholic delirium.

sodium bromid in 1000 c. A similar function is served by the warm of pack. the ends are then knotted under the cot or securely fastened to the sides of the bed. the most humane. If the emergency . Hogan noted rapid subsidence of the delirium. The solution of glucose c. imperative. In a similar man- ner the legs may be fastened by a rolled sheet which encircles is separately each ankle and bed.c. The various substances had best be dissolved separately in freshly distilled water in the proportion of and boiled. Thus. such as a fracture of a leg. to thrust his nails into his eyes. requires equal care in itsipreparation.2 gm. are. may be that he has suffered a serious surgical injury. of course. indeed. a patient c.TREATMENT bicarbonate. but.c. Here the warmth and the free sweating induced are likewise factors conducing to the relaxation and the calming the patient. in exceptional instances. is 80 gm. g. only infrequently resorted physical restraint is However. of glucose to 240 of water and. Usually a sheet or sheets properly applied answer every purpose. 455 of water. and 10. to strike his head against the wall — or he may be engaged ings in a constant and exhausting struggle with his surroundAgain. may be con- stantly endeavoring to injure himself. and most physiologic form of re- straint yet devised.3 per cent. then fastened to either side of the An excellent restraining sheet which allows considerable freedom of movement and yet prevents injury to the patient can be secured at most instrument makers. loosely rolled A sheet may be passed back of the patient's neck and under both armpits. the successful after-care of which demands quiet. The continued warm bath it is also a form of restraint.. of his cases. is also a method of re- Other forms of restraint to. it and attendants. or perhaps it has been necessary to submit him to some surgical operation. in the modern asylum. while recovery ensued in between two and three days in all is but 9. the pack straint. in addition. the best.

important to point out that a patient under physical restraint should be carefully watched.. only infrequently required. the legs extended. Such measures are. attention to the digestive tract. However. also. for it is quite possible that he Finally. be separated from the quiet ones. Sedatives or hypnotics should be given at the (See p. the judicious use. of sedatives to allay agitation and the institution of measures. properly made and properly applied. so as to his transfer to make possible an asylum without injury. Disturbed cases should. It is needless to say that they should be It is removed as soon as practicable. must be taken in . The feeble and in- firm and those that are sick naturally require special attention and provision. drugs should be used only at times and to tide over special periods. Special precautions. g. these include a liberal diet. closed sleeves and laced up the back —a canvas —and can. The same if is true of anklets and wrist- lets. however. and the sheet then firmly secured by means of safetypins. e. are to be followed. lest the latter also become excited. 421. the correction of constipation.456 MENTAL DISEASES it makes necessary that a greatly disturbed patient. be restrained entirely. In the management of the mass of patients in an asylum. Much a rule. such as open air exercise and occupation to combat sleeplessness. when necessary. suicidal cases. there can be no objection to their use under certain circumstances and in given instances. of course. in acute mania. general principles. restraint. prejudice exists against the camisole with long. the arms being flexed over his chest.) same time. as it shirt be dispensed with. in cases in may injure himself in spite of the restraint. he can be completely rolled in a sheet. of course. which an emergency necessitates this we should not rely upon measure alone to control the patient.

and. women in sewing. it is to be hoped. to play games. cooking. improved cases of dementia prsecox may be more or less retrained. The entertain- but they should be entered upon with caution. 457 and chronic Light cases should be encouraged to read. quiet. there have been established hospitals patients for the chronic insane. field work. also hospitals for the criminal insane. and Of recent years the tendency has been of patients in special hospitals. Diversion and amusements may also be arranged. and the future promises that the high-grade classes will also soon defective and criminal be made the sub- jects of a similar provision.TREATMENT As far as practicable. and gardens. A method of caring for the insane in families has long been in existence at Gheel in Belgium. it is doubtful whether and kindred functions have a place in the asylum. be interested in laundry to which they are accustomed. tasks should be imposed upon some. while the criminal insane often become orderly and well behaved. that ere long inebriates. in addition to the general hospitals for the insane. Often patients who are mischievous. and epileptics are. location. and employment size. For certain classes of cases . to some extent. already segregated in special institutions. in which the work in shops. are greatly benefited by such means. and cases of paranoia become interested in something other than their delusions. gardening. in we will have adequate hos- pitals for which the patients cannot only be Feeble-minded children usefully employed. destructive. By means of occupation. work Men should. upon others. toward the grouping Thus. the convalescent. in which the patients are similarly occupied. farms. but also detained. or given to masturbation. The classification of patients depend of facilities possible course largely upon the in a given hospital. work. when possible. an occupation. ments provided should not be balls exciting.

and from which the cases proving to be chronic or incurable may be distributed to the appropriate asylums.458 this plan MENTAL DISEASES has much to recommend it. If these families could be the families of attendants regularly in employed the hospital itself. so that the hospital could still keep in touch with them. he leaves too soon. he remains too long. Perhaps a useful adaptain tion of it would be to have suitable cases as they improve the hospital transferred to families in the neighborhood. or the friends should be informed of the importance of having the patient report to the hospital or clinic at intervals. very satisfactory arrangements could probably be made. he may relapse. as well as the difficult matter of judging just tient when a convalescent paIf had best leave the if institution. Such a plan would meet largely the im- portant problem of the "after-care" of the insane. More important than all of the above measures is the founda- tion of psychiatric hospitals in cities in which the acutely insane will be received and treated according to the most scientific methods. he may become discouraged or indifferent. dismissed cases should be own homes. . traced to their When practicable.

247 dementia and. 350 After-care. Adult age. 458 clinical picture. 350 insanity as related to. 339 old. 219 Acuter Wahnsinn. 412. 349 mental diseases as related to. early. 48 Alcoholism. 221 diagnosis. 441 prognosis. 224 confusional insanity and. 330 Amaurotic family idiocy. 28. 219 delirium tremens and. 220 epileptic delirium and. insanity in. insanity in. 49 multiple neuritis. 223 Adrenal disease. adult. 212 in tabes. difinsanities. 48 hallucinations in. 338 Agoraphobia. 130 prognosis. 315 athy. 403 Alcohol Aboulia. 419 autopsy. insanity in. 222 entiation. 49 in Abaissement du niveau mental. differentiation. 46 Alzheimer's disease.INDEX dementia prsecox. 339 Agitated melancholia. 214 intercurrent delirium of paresis symptoms of. 246 confusional insanity. differenparanoia. differentiation. 212 ferentiation. 108. 196 in production of inherited 459 . 454 See also Dementia prcecox. 457. 413 symptoms. 35. 349 treatment. 212 etiology of. 343. 278 action of. insanity in. 213 Amentia. 49 Alienation. Korsakow's psycourse of. 220 tiation. 111 neuropAbscess of brain. 130 delirium. 74 symptoms. 345 juvenile form. 344 paresis and. dementia. 218 Acromegaly. 186 Amblyopia in paresis. 350 Age. 49 hereditary. differprognosis of. 223 Afebrile delirium. 343 223 mature. 45 prognosis. 34. 21 symptoms. 279 Alcohol. 213 pathology. salt solution in. 216 Adiposis. degree of resistance to Ameboid pupil in paresis. 49 delusions in. 320 effects of. differentiation. 46 chosis in. 218 Acute Verriicktheit. 330 symptoms. 344 eye-grounds in. 113. insanity in. 240 intravenous injection of normal Adolescent insanity. 48 treatment of. 338 middle. 317 AlcohoUc confusion. 214-216 and. early. 45 chronic. 343 physical signs.

58 duration of etiology of. 339 treponema pallidum in. 317 hysteric sjonptoms in. 121 stupor. 225 Association in dementia praecox. warm. Atrophy. 39 Circular form of paresis. 280 Arteriosclerosis. 285 Bestiality. 87. deUrium insanity in. 314 Apperceptive dementia. 54 Children. 99 Blood in melancholia. paranoia in. 126. life of. cerebral. 86 Attitude in melancholia. commitment treatment in. 286 Bones. 279 Attention. to. 266 Bell's deUrium. education and training: Bath. 333 dementia prsecox. differentiation. 312 Charcot joint See also in paresis. 415 in afebrile deUrium. 398 Asylum. 143. 288 Huntingdon's. 336. 251 332 330 suicide in. 318. 318 atrophy of. 341 treatment of. 62. 113. 318 tumor of. 318 symptoms. 332 in. 124 in mania. 257 Ankle clonus in paresis. locomotor. 445 outside of. 317. 310 thrombosis. in mania. 71 Circulation in paresis. abscess of. 88 test for repressed Bright's disease. 420 ChloraUsm. 455 of. 336 stupor in. 59 Cerebral apoplexy. in. 315-318 Anthropophobia. 256.460 Anesthesia in hysteria. Childhood. 313 emboUsm. 70 Arc de cercle in hysteria. 236 Bathing in treatment. 71 states. 361. and. 312 suicide in. Automatism in in in confusion. 314 hemorrhage. in paresis. 314 arteriosclerosis. 340 339 mental tests in. 276 Apoplexy. 371 nervous. 352 Babinski's sign in paresis. 289 Borderland manic and paranoid Circulatory changes in melancholia. in paresis. 315 hallucinations in. 265 Bed-sores in paresis. of epilepsy. stupor and. feeble-minded. 242 See also De- Catatonic stupor. mentia prcecox. 451 Chorea. 241. 277 Bastards. 30. 403 Appetite in dementia praecox. fault of. differentiation. 67 Aura. 340 hypochondria in. 331 myxedema in. 417 Ataxia. confusion 290 332 Tabes. 186 Anxiety psychoses. lead. in melancholia. 407 in hypomania. multiple. changes in. 314 syphilis. 242 Cancer of Catatonia. 277 INDEX Brain. 313 Arthralgia. 414. 267. 144 . 91 loss of. 452. psychic. 313 symptoms of. in paresis. 275. 362 insanity. 260 Argyll Robertson pupil in paresis. 314 Cerebrospinal sclerosis. 94 in mania. 315 symptoms. optic. stomach. 31*2 paresis or submerged 417 complexes. 185 Apoplectiform attacks in paresis.

138 d'embleo. 20 prognosis prognosis senile. marriage of. Cretinism. 304 Coma. 261 55 50 diagnosis etiology of. 138 aigus. passive. 452 Deception in hysteria. of. 234 441. 363 hypnotics 424 in childhood. interrelation. lead. 417 Communicated insanity. 210 in coprolaha in. 218 prognosis of. 130. tic in. treatment. ogy of heboid-paranoid group. 195. 218 Crystallophobia. 30. 34. 414 Cranial nerves. forms of. 279 in. double. 56 Definitions. 337 Criminality. 52 354 moral. Curable dementia. Commitment to asylum. 130 Delirious mania. 39 . 332 in epilepsy. in. 241 78 Contagion. 253 Deficient inhibition. 90 52 of. 28. 440 Cousins. 186 and deUrium. acute. diabetic. 177.INDEX Circulatory disturbances in neurasthenia. 56 Degeneration. insanity by. 190 Confusion. 56 Cutaneous sensibility in mania. 443 Colic. 261 in malaria. in epilepsy. insanity of. of. 27. 225 Colloidal gold test in paresis. 17. entiation. 50 alcohoHc. 424 in tuberculosis. trauma of head. states of. 377 prognosis. 186 Cocain bug. stigmata in etiol- 55 346 of. 183 Classification. 110 Delire du toucher. 49 chroniques. Daucrbad. urine 238 239 uremic. 49 afebrile delirium and. alcoholic. hallucinatory. 322 192 209 nourishment in. in paresis. 219 Consciousness. thyroid extract in. 336 desiccated thyroid physical signs. onset of. 70 Constitutional emotional depression. 192 treatment. high-grade. 382 Convulsion in hysteria. 233 hallucinations in. 260 in paresis. 235 Cocainism. sanity. 197 Delires symptoms treatment 52 423 differ- systematises 131. 275 Convulsive tic in insanity of deficient inhibition. 52 of. 29 and stupor. repression of. 190 in hysteria.392 341 Compulsion neurosis. insanity 196 of. Daemmerzustand. 29 course of. 49 active. 50. 235 symptoms treatment of. interrelation. 26 254 Constipation in melanchoha.388. 178 in neurasthenic-neuropathic in- 461 Confusional insanity. 377 Complexes. 354 sexual. paralysis of. 354 387. 49 in. 439 will. 264 Deficiency. 192 of. 191 suicide in. of. 196 tic convulsif in. Confusional insanity. Claustrophobia.

48 See also Delmum. 422 postfebrile. 108. 323 nourishment in. 77 mania. 421 with morphin in. 225. 211 in trauma of head. afebrile 48 and. 260 in childhood. symptoms specific. and. 419 tremens. 48 prognosis of. 423 of exhaustion. 244 and. 45 delirium of pare- intercurrent sis puerperal. 39 hydrotherapy in. differentiation. 89 . 44 40 43 differentia- dementia praecox. definition Delusional insanity. unsystematized. expansive. 31. 30 febrUe. Delusions in alcohoUc paranoia. 115. dif- ferentiation. 49 course of. 24 138. 35. 420 wet pack in. 35 course of. 45 of. definition of. 421 simple. 407 of. 39 afebrile. 45. scopolamin in. 327 and. afebrile. 216 pathology intravenous injection of normal salt solution in. 23 of the unpardonable sin. differentiation. hysteric. etiology of. toxic. definition 24 24 39 of. epileptic interrelation. definition of. 49 paraldehyd in. duration specific of. hypochondriac. 45 trional in. 49 intercurrent. depressive. 35 of. 34 delirium afebrile and. 421 thyroid. 421 in. differ- delirium deUrium and. BeU's. differentiation. 25 course delirium diagnosis 40 tremens of. specific febrile delirium differentiation. 34. 420 hyoscin in.462 Delirium. 119 in in hypomelanchoha. 49 218 delirium differentiation. differentiation. differ- 332 plumbism. entiation. 45 of paresis. 49 of. prognosis symptoms 45 40 grave. 23 of. 37 of. 45 insanity in confusional and. 35 etiology of. 421 See also Paranoia. 49 symptoms of. 34. INDEX Delirium. 221 in dementia prsecox. delirium diagnosis epileptic 46 tremens of. 34 acute. 24 in melancholia. 226 in rhemnatic fever. with sulphonal in. of. definition pathology toxic tion. 29 treatment of. 422 sedatives in. 68 somatic. deUrium and. 23 warm bath prognosis of. dif- ferentiation. 48 febrile and. and. 419 alcoholic. 46 treatment of. 420 Delusion. of. of. 25 in insane. 139. diagnosis etiology 39 39 37 of. 27. definition of. entiation. 39 definition of. 243 prognosis of. 45 etiology of. systematized. 216 afebrile delirium and. 45 454 and confusion.

121 Wassermann primary. differentiation. psychology pupils in. 136 hallucinations of. depression 129 in. 128 in malaria. 113. 407 111 of. treatment 109 433 verbigeration in. 122 transmission of. 127. of. 129 duration prognosis paretic. 56 alcoholic. Dementia 146 116. 403 period of. 105 203 delusions in. 134. 117 complexes repressed Freud's in interpretation of. prjBcox. 135 138 . 68 in paranoia. 111 before puberty. suicide in. 247 210 lead. 32. hallucinations in. in. 266 epileptic. ing features. 31. 134. catatonic 345 differ- features. 123 prognosis. 123 memory in. paresis and. constitutional emotional. 129 of mental level. 131. 136 129 in. praecox. 105. 331 in famiW. of paresis. entiation. 130 78 dementia . 406 germ plasm in. 282 202 acute. 284 hebephrenic form. 223 insomnia in. 130. 202 of. 407 as result of stupor. 223 dementia and. 118 negativism in. 83 in mystic paranoia. of. in. 128 in paresis. 56 definition of. 129 paranoid. 28. 120 mental impairment in. 136. 109 form. automatism cases of. 129 137 127. 124 expansive period in. 114. prognosis of. in mania. 136 sex glands suicide in. 224. 130. 111. 111 appetite in. differentiation. 128 physical signs. 202 reaction in. 130 depression in. 408 224 number of cases in family. 223 prognosis curable. 121 nerve substance in. 114 124 s^'philis in. prognosis course. 114 of. 406 distinguish- paranoid dementia. 226 paralytic. 125 130. 129 paranoid dementia. 131. absence of psychic reflex alcohol in.INDEX Delusions in melancholia. 115. 128 simple form. 202 senile. 203. 127. 123 in. 156 in in enlargement of thyroid gland in. forms of. in. distinguishing secondary. 113 symptoms. symptoms terminal. 351 clinical pictures. distinguishing features. 109 paranoid form. 116. in. 132 hallucinations of. duration prognosis of. 127 course of. 60 depression 116 Depression. 127 course of. in 463 prsecox. 119. 402 131. 125 266 in. 128 delusions 127. 124 associations in. 135 Demented form Dementia. 127. 124 masturbation in. 108. 129 delusions in. 130. 126 senile melanchoUa and. of.

252 24 form of paresis. 252 Fears. 247 Fear in neurasthenia. 48 Digestion in mania. 248 Febrile deUrium. 244 symptoms of. 243. nocturnal. hematoma of. 116. 283 aura of. in paresis. 186 duration of attack. 275 in Digestive disturbances neuras- Episodic mental states in epilepsy. 253 253 of. 187 etiology of. Epilepsy. 225 in. differentiation. 252 larvated. 175. lead. 197 Dissociation. 185 episodic mental states in. 254 Expansive delusion. 338 Fatigue in neurasthenia. 238 urine in. dementia prsecox in number of members of. 395 Dreams in production of symptoms. Enema. definition of. 158 Dysthyroidism. 166 Diplegic idiocy. 289 Embolism. 250 Erotic symptoms in paranoia sim- 183 plex.464 Depressive delusion. 24 form of paresis. 251. 34. thenia. 117 mental Extramural treatment. 335 Dipsomania. 394 psychology of. nutritive. of. 110 Diabetes. 253 181 double consciousness in. 262-265 Dream-displacement. 339 Facial appearance in paresis. insanity of. 432 Enlargement of thyroid gland in dementia prsecox. 254 of open spaces. 341 Deviation and arrest. 243 Exhaustion. 247 Epileptiform attacks in paresis. morphological arrest and devia187. 91 in paresis. 193. confusion in. 180. 109 idiocy. 251. in melancholia. afebrile delirium and. 247 masturbation and. changes paresis. 238 prodromata 251 sequelae of. 251 somnambulism stupor in. 281 of paresis. 181 Epilepsy. 384 Dormeh. 249 Diabetic coma. stigmata of. 277 Eye-ground. 253 psychic. in etiology of heboid-paranoid group. special. delirium in epilepsy. 314 Encephalopathy. 243 Ear. Double consciousness personality in hysteria. 239 Epileptic delirium. amaurotic. 279 in amaurotic. 397 therapeutic appU cation of. Desiccated thyroid in cretinism. 176 . of. 177 in neurasthenic-neuropathic insanities. in paresis. 274. symptoms 248. 187. 157 Euphoria in tuberculosis. 251 of. 178. 287 dementia. 35 276 Family. diseases Doukhobors. 209 45 Exophthalmic goiter. 252 sexual trauma in etiology of. 417 Eye symptoms in juvenUe 396 243 280. 188 hallucinations in. family idiocy. definition INDEX of. 250 etiology. 124 neurosis. 284 period in dementia praecox. Ductless glands. 188 tion in. of.

35 465 Grave delirium. 44 etiology of. 188 course of. 165 of Fetichism. 89 in melanchoUa. exophthalmic. 380 du doute. 141. 155 in paranoia simplex. Gait Hallucinatorische Verwirtheit.INDEX Febrile delirium. 166 147 visceral. 52 Hallucinatory confusion. 128 283 in plumbism. 333 340 339 mental tests in. 302. colloidal. in paranoia. 277 Gastro-intestinal form of hypochondria. 225 in puerperal delirium. definition 220 in cocainism. melanchohc. 127. 40 patliology of. simple. 243 Globulin test in paresis. in pare- simplex. 267 paresis. 429 in paranoia. in Gout. 116. diseases of. 74 Freud. 143 prognosis of. 247 simplex. 211 in in paresis. 433 267 Glands. 380 communiquee. 165 sexual. 160 entiation. in tumor of brain. in melancholia. 188. forcible. 40 delirium tremens and. 240 in mania. smeU in paranoia. 363 Folie k deux. 22 Hallucinations in alcoholic paranoia. 144. 317 Feeding. 147 of. 145 240 simplex. 240 hallucinations 30 in. duration of of. 165 of poisoning in paranoia. of hearing in paranoia. 144. 322 delirium in. 234 tremens. 145 differ- toxic delirium and. 138. 145 448 simplex. 39 course of. in delirium differ- of. 165 of vision in 288 mystic paranoia. treatment. Hallucination. 375 General paralysis of insane. 37 of. 429 full. 197 Foot. in paranoia. sjTnptoms of. hallucinations paresis. paranoid dementia. 389 Functional nervous diseases. life of. 244 Handwriting in paresis. 341 treatment of. 37 specific. 243 Gold test. 43 prognosis of. 165 . 328 in rheumatic fever. simplex. 69. 77 in paralysis agitans. in mel- 304 anchoha. Hearing. 40 diagnosis etiology of. 39 symijtoms of. 266 in in epilepsy. 303 Goiter. 39 Gruebelsucht. 155 Forcible feeding in melancholia. in mystic paranoia. 323 of. 281 Head. 147 of sight in paranoia simplex. 147 of taste in paranoia. 321 confusion in. 267 in paresis. ductless. 69 in paranoia. 148 Frenzy. 217 dementia praecox. perforating ulcer sis. entiation. 45 symptoms of. 406 252 in gout. trauma of. 52 paranoia. 362. 172 progressive. 45 Feeble-minded etiology cliildren. 45 diagnosis of. 243. 340 in treatment. 39 35 prognosis of. 70.

260 confusion in. 77. 421 Hyperesthesia in hysteria. 264 etiology of. differentiation. 243. 254 double personality in. 336 symptoms of. 76 Homosexual delusions in. 94. 374 deception in. 243. 94 98 Hemianesthesia in hysteria. 256 366 hj'pochondria and. sexual instincts 95 High-grade deficiency. 368 hemianesthesia in. 76. 376 . 447 Hyoscin in delirium. 375 definition of. 77 Huntingdon's chorea. 314 Hemorrhagic pachymeningitis in paresis. 289 course ideas in of. 257 Hyperthyroidism. 375 sanity. 99 in. 98 physical signs. suicide in. 108 of paranoia. 427 paranoia and. states History. 260 course of. 108 stupor cases. 183 Hebephrenia. 95 nourishment in. 247 anesthesia in. 289 Hereditary alcoholism. 129 Hypodermoclysis in treatment of Heboid-paranoid affections. 261 Hypochondria. 141 diagnosis in. 261 hereditary factors in. 256 hypesthesia in. 375. 266 prognosis of. 360. 366 gastro-intestinal form. 254 Hyperpinealism. 98 of. 78 Hutchinson's pupil in head injury. differentiation. 354 s>nnptoms of. Hematoma of ear in paresis. 420 Hypothyroidism. 454 neurasthenia. 262 Hemiplegia in paresis. 256 arc de cercle in. palpitation of. 255 delirium in. 426 Hypomelancholia. hyperesthesia in. 77 love. 262 melancholia and. 275 Hemiplegic idiocy. 98 paresis and. 125. Dementia prcecox. 377 anxiety of patient in. 17 of. 366 Heredity in etiology of heboidparanoid group. 77 Hypopinealism. ISO heredity in etiology of. symptoms of. See also Hypochondriacal form of paranoia. 78 322 Hydrocephalus. differentiation. 369 convulsion in. physical signs.Hypochondriac delusion. 213 factors in hypochondria. 370 254 sexual form. 113. 366 hysteria and.466 Heart. differentiation. 256 Hystera. 31. 247 Hydrotherapy in delirium. 94 treatment of. 25 mental make-up of. 432 stigmata of deviation and arrest Hypomania. 1 10 association in. 447 Hypesthesia in hysteria. 108 of salt solution in melaricholia. 93 in etiology of. 335 Hemorrhage. 344 memory in. 262-265 in childhood. 365 premonitory. 255 Hysteria. 256. of. 410 duration of. 178. 364. 98 prognosis of. 256. differentiation. INDEX in Hypochondria. increased flow 94 middle age. 152 Heboid-paranoia. 368 in neurasthenic-neuropathic in. 363 contagiousness of.

263 prognosis. 333 definition of. 132. treatment of. 195. 377 confusional. 138. 330 by contagion. 191 suggestion in production visceral. tendencies. insanity of. 257 Inhibition. differ- 340 Idiots savants. 333 amaurotic family. 321 318 of. 377 prognosis. insanity of. 335 Dementia pr(Bcox. 31. definition. 259 suicide in. 87. 85 in pyromania. 257 neurasthenia and. 188 261 in. 335 moral. 49 alcoholic. Infancy. 333. 30. 196 tic convulsif in. 261 psychasthenia tion. deficient. 257 Inframammary tenderness teria. insanity in. somnambulism stupor in. 113. 23 Ideas. increased flow in hypo- general paralysis of. 190 Incoherence in mania. 376 Impulses in mania. 88 differentia. 339 classification of. 254 opisthotonos in. 343 Mongohan. . 439 Injuries of head. 108. Insane delusion. Illusion. symptoms 256. 257 pyschic. 218 of. psychic. 22 prognosis Imbecihty. 343 treatment of. duration. treatment. 17. 334 definition of. 219 as related to age. 190 treatment of. Insanity. 60 course. 330 in 259 Infectious diseases. 335 learned. 177 in production of symptoms of. in. 21 diplegic. 219 20 delusional. 467 inframammary tenderness 257 inguinal tenderness in. 60 Indecision. 212 confusional. 94 in mania. suggestion 262 Indigestion in neurasthenia. 88 Idiocy. 193 Impulsions. 139. hys- motor. 218 prognosis of.INDEX Hysteria. 439 Impulsive movements. 190 treatment of. 61 spinal tenderness in. 21 definition of. 256 257 Inguinal tenderness in hysteria. 61 255 in. 190 somatic. 99 classification of. 62. 382 circular. treatment of. 49 also afebrile delirium and. 357 morphologic. 260 ovarian tenderness in. 257 440 differentia- 192 192 tumor tion. 335 hemiplegic. 267 See mania. of brain and. 257 symptoms. 207 of. 340 See also Paranoia. 439 259 and. 258 sensory. Impotence. adolescent. 334 pathologic. 257 paroxysm of. entiation. in. tic in. differentiation. 28. alcoholic. definition of. 26 communicated. 108. 257 coprolalia of.Incomplete stupor.

Irritability in neurasthenia. 344 in middle age. 224 pathology prognosis moral. by paraldehyd. cocain. increased. 188 partial. insanity with. Intraspinal 113. 89 in neurasthenia. 357 prcecox. 175 treatment. 101 of. 108 stigmata of degeneration in etiology of. 56 juvenile. Dementia lead. 183 prognosis suicide of. tic in. increased. 441 trional. 31. alcohol. 184 196 symptoms 183 physical. 224 by medinal. heredity in etiology of.^8 108 INDEX Insanity of double form. 184 palpitation of heart in. . of. 99 330 mature adult age. Irresistible impulse. 62. 99 of indecision. heboid-paranoid group. in precocious. 183 Intracranial pressure. Insomnia in dementia praecox. 31. 184 343. 138. 345 stuporous. 282 Intramural treatment. treatment 183 441. in psychic. 331 in early adult age. 188 Insanity. 441 course of. 212 neurasthenic. 187 masturbation and. periodic. changes in. paresis. 383 19 in old age. 227 treatment treatment of. 330 suicide in. 32. 32. Intoxications. melancholia lodids in paresis. 197 in. 195. 177 106 101 of. 17 in childhood. of special fears. 344 190 coprolaUa in. 113. 196 tic convulsif in. paresis. 290 will. 439 290 Charcot. 237 by by treatment of. 185 etiology of. 184 thyroid insufficiency in. 343 See also Par- anoia. digestive disturbances in. 237 by morphia. irresistible impulse. 197 by lead. 191 smcide in. 124 in mania. 175 circulatory disturbances course of. 195. 192 treatment 196 of. 187. 185 inadequacy in. 190 282 Involution. in paresis. 183 441-444 441-444 forms of. 237 by sulphonal. 443 neurasthenic-neuropathic. 31. 139. 304 of. prognosis 197 by by chloral. 233 treatment 434 in. 108 psychology of. 110 history of. pressure. 227 of. 180 289. 434 108. See also Dementia proecox. 236 of. 445 treatment of. of deficient inhibition. 28. by opium. 289. in of adolescence. in paresis. 344 in infancy. of. 108. 237 veronal. 192 Joints. 237 sexual disturbances in. 190 manic-depressive. 188 sexual trauma in etiology of. See also symptoms with of. 212 by 197 of. 187.

30.INDEX Juvenile form of amaurotic family idiocy. 225 Learned idiots. borderland. 324. 91 Manic state. 347. fault of. 199 Light reflex in paresis. 86 hallucinations in. See also insanities paralysis. subacute form. 39 delusions in. 220 Labor. 280. 93 symptoms of. Tabes. 82 fault of attention in. 304 Larvated epilepsy. 91 Lucid melancholia. incoherence muscular efforts in. impulses in. 92 etiology of. paresis. 421 sodium. 280 Little's disease. Knee-jerks in paresis. 219. 87. increase of. mentia prcECox. 251. 90 in. 88 . 209 210 210 prognosis of. 329 duration of attack. 113. increased 87. 81 confusion in. 210 Malarial paresis. 82 temperature in. 87 urine in. 93. 91 state of mind 84 Malaria. 113. 210 Malignant disease. 324 Lactation. 281 Mania. hallucinatoria. 351 in. Kleptomania. 88 ' 91 101 physical signs. 242 Mania. 82 See also cutaneous sensibility in. special senses in. 270 eye symptoms. 90 decline of symptoms. 52 Lange's colloidal gold test in paresis. saliva in. 31. 453 Lymphocytosis in paresis. 352 Manic-depressive insanity. 252 88 illusions of perception in. 165 Luminal. attention in. 469 339 108. 91 pathology. 91 thoughts in. Lead coUc. 101 assoQiations in. 327 in. 92 definition of. 197 of. 336 Locomotor ataxia. 303 secretions 91 senile. 225 to. 277 Korsakow's psychosis. 89 83 92 91 Katatonia. 226 encephalopathy. 278. 241. . 193. 92 menstruation in. 318. 85 in. 86 course of. 91 in. 79 Lucidity in paranoia simplex. Dementia proecox. 84 states. ideas in. in. 85. 81 delirious acute. 126. See also De- depression diagnosis digestion in. 224 225 poisoning. period of depression perspiration in. 106 prognosis. 101 appetite in. 224 rheumatism. 224 dementia. due 88 89 masturbation in. 89 flow of. dementia in. 31. 90 memory in. 62. 343 L'6clipse mentale. 224. 85 insomnia in. 62. puerperal. 92 mental attitude in. insanity. 422. 90 prognosis pulse of. 302. 86 Lavage 432 of stomach in melancholia.

67 71 351 senile dementia and. 71 in. 30. duration. 75 blood in. 72 prevention of. 79. loss of. 188 skin in. 70 with agitation. differentiation. psychic pain pulse-rate in. 75 circulatory changes 71 paranoia and. 69. 101 diseases as related to age. 105 appetite in. 106 Melancholic frenzy. 426. 73 stupor and. 414 of cousins. 330 . 75 diagnosis. differentia351 in. 65 temperature in. 75 59 subacute form. stupor and. 79 worry in. 430 Memory in dementia prsecox. 429 77 hallucinations in. 62. 432 lavage of stomach in. 92 of involution. 79 suicide in. 75 diagnosis. 428 duration. 59 nasal feeding in. 68 65 forcible feeding in. tiation. 85 prognosis of. 71 visceral signs of. 67 attonita. 75 appearance of paranoid attitude in. 79 duration. 66 a66 hypodermoclysis of salt solution Melancholia-mania. constipation in. 30. differentialucid. differentiation. 76 suicide in. 95 nursing in. 79 tion. 70. 90 sitiophobia 71 special fears and. 428. sine delirio. 65 in. 414 Masochism.470 INDEX Melancholia. 75 prognosis. tion. with stupor. 432 Menstruation in mania. 63 in. in. 71 respiration senile. 81 of. 451 Masturbation in dementia praecox. 71 in. 237 Melancholia. 75 contagiousness course of. 62 frequency of. differentiation. 361 Massage in treatment. 70 attitude in. 64 agitata. 79 duration. 92 nutritive enema in. 432 pathology of. 70 of weight in. 120 nourishment in* 429 in hypomania. 75 381 prognosis. 81 definition of. 344 Mental attitude in mania. 429 in mania. 31. 71 stupor. 74 stuporous. 78 course of. 427 urine in. differen- course. 74 course. 71 treatment of. 413. 81 of. Mattoids. 70 of. 75 symptoms paranoia and. symptoms. 79. 64 delusion of unpardonable sin delusions etiology in. 123 in in. 352 starvation Medicinal intoxication. 68 prognosis. 74 loss of appetite in. hypochondria and. Marriage in neuropathic ancestry. 79 mania. 104. 80 without delusions. 187.

181 Morons. 197 155 prognosis of. digestive disturbances in. 361 forms of. 354 Morphinism. 176 myokymia in. 176 Korsakow's motor. raslhenia. 357 idiocy. course. 154 hallucinations of vision in. See also N'eu- Neurasthenia.*344 insanity in. 344 Mind. 25 Monophobia. 176 fear in. 246 circulatory disturbances •course of. mental exhaustion in. See also Paranoia. 180 treatment of. 177. 175 25 Mysophobia. 186 Moral deficiency. symptoms alcoholic. 156 155 treatment of. and. 175. 434 Neurasthenic-neuropathic disorders. 336 245. 178 312 paresis rest cure in. differentiation. definition insanities. 178 definition of. Neurasthenic. 430 Necrophily. 84 weakness. 121 183 . 197 in. 198 Mongolian idiocy. 434 in. 185 inadequacy in. 271 pulse in. 228 hysteria and. children. and Mercury in paresis. 184 palpitation of heart in. digestive disturbances in. 434 of. 177 in. 237 Middle age. 183 Nasal feeding in melancholia. 178. 230. 177 insomnia in. 176 strength in paresis. 471 in Nerve substance 408 dementia prajcox. 90 exhaustion in neurasthenia. 289 mania. 247 functional. 183 symptoms of. 175 circulatory disturbances in. 198 in neurasthenia. 177 fatigue in. 180 treatment of. hyponiania in. 179 sensory. 178. differentiation. sexual disturbances 178. 176 psychic. 32. 177 when poison 231 is withdrawn. in mania. 177 efforts in somatic. 415 Metabolism. of. 179 muscular exhaustion in. 138. palpitation of heart ISO paresis and. differentiation. 266 prostration. 254 indigestion in. 178. 276 Myokymia in neurasthenia. 32. 179 ^ 312 neuritis. 248 Multiple cerebrospinal sclerosis. 334 Morphological arrest and deviation in epilepsy. of. 177 psychosis in.INDEX Mental exhaustion 179 weakness. 335 Monomania. 187 Mystic paranoia. education Nervous diseases. 245 in children. 227 symptoms of. 441-444 Morphologic idiocy. disorders of. 247 organic. 197 period of depression sexual hallucmations in. 354 357 insanity. Negativism in dementia praecox. 177 tachycardia in. in. 219 Muscular changes in paresis. 310 training 414. state of. 139. 180. 175 Myxedema. irritability in.

184 in. 332 of vision in. 145 Obsessions with cies. fear of. 181 intoxication. 143 in unmarried. definition of. 140. 175. 147 190 in. 190 fatigue. 266 Originare Vernicktheit. in psychasthenias. 188 alcohohc. 140 143 in neurasthenic insanities. compulsion. 143 chronic. melanchoha. 227 treatment of. 148 hallucinatory. 423 in dementia precox. 267 Paralytic dementia. 140 prognosis of. 143 frequency of. Kor. 267. 147 Opisthotonos in hysteria. sexual disturbances suicide in. 429 of insane. 180 symptoms of. 143 hallucinations in. 197 in 289 symptoms of. 138. of. irresistible tenden- of hearing in. Old age. of insane. heredity in etiology 141 hypochondriacal form. 345 186 of smell in. 183 in. 147 of taste in. 108. 129 433 of. 428. Ovarian 257 tenderness in hysteria. 138 acute. 219 Neuropathic. 67 Palpitation of heart in neurasthenia. 139 in. 172 treatment heboid-. 130. 31. insanity from. in stupor. 420 Pain in paresis.Paraldehyd in dehrium. in confusion. 267 lead. 25 Neuropathy. 382 Nutritive enema in melanchoha. 279 Organic nervous diseases. 225 Nocturnal epilepsy. Paranoia. 427 in in hallucinations 220 in. 424 delusions in. 145 of poisoning in. 144. 220 Nourishment in delirium. 434 combinatorische form. definition of. 195. 266 general. 302. 143 in persons born out of wedlock. 186 in bastards. 434 alcoholic. sanity. 260 Opium poisoning. 183 multiple. 178. Neurasthenic-neuropathic d sor ders prognosis of. 222 145 auditory hallucinations course of. psychic. 266 hallucinations in. insanity Open spaces. 428 neurasthenia. 279 progressive general. 237 Paralysis agitans. 472 i INDEX Pachymeningitis hsemorrhagica paresis. 152 . in afebrile dehrium. 253 Noguchi's discovery in paresis. 146 forms of. 25 Neurosis. physical. 267 Nonne globulin test in paresis. 318 of cranial nerves in paresis. in melanchoha. 196 184 Pack. wet. 143 434 delusions 425 Nursing in melancholia. 272 psychic. of. 132 303 Nosophobia. 221 in. prognosis of. 183 thyroid insufficiency 184 in neurasthenic-neuropathic in- treatment Neuritis. 140. 434 definition of term. 432 Nyctophobia. 441-444 Optic atrophy in paresis.. 422 sakow's psychosis in. 433 in hypomania.

266 age occurring. 276 Argyll Robertson pupil in. 302. 352 Paresis. 154 and. . 304 hallucinations in. 155 period of depression sexual hallucinations in. in. differentiation. appearance in. 283 erotic symptoms in. 278 ankle clonus in. 169 originaria. geographic. 127 course of. in 129 in. 172 sexual hallucinations in. in. 130. 275 onset of. of litigation. afebrile 347 simplex. in. 165 duration etiology of. 270 alcoholic dementia and. 161 prognosis. prognosis of. 433. 434 skull in. 283 diagnosis digestion of. in. 290 circular form. 269 globulin test in. 128 states. 159. hypomania 98 and. 172 304 psychology of. 105 self-accusatory form. 277 facial in. 165 of sight in. colloidal. lucidity in. 75 hallucinations of vision in. 165 300 287 distribution. 166 symptoms of. 136 hallucinations prognosis. in. 279 Charcot joint in. 269 of taste in. shape of. 279 ameboid pupil in. 141. in. 282 gait in. 283 forms handwriting in. in. hypomania and. 292 in. 160. delirium and. hallucinations 160 of hearing in. 280 Babinski's sign bed-sores in. 277 332 in. differ- entiation. 290. 276 of. 277 general. 113.INDEX Paranoia. 131. 149. 147 Paranoid attitude. 161 267 syphilis. 267 expansive form. 149. differentiation. 286 colloidal gold test in. 275. delusions 128 281 depression 129 in. borderland. 140. 166 depressive form. 473 98 agitata in bastards. 144. suicide in. also Paranoia simplex. 433 visceral hallucinations in. 165 epileptiform attacks of. 223 amblyopia in. 49 in. 141. 129 of ear in. 155 See non-hallucinatory. 143 treatment of. 277 apoplectiform attacks in. 289 duration. 409 convulsions course of. 267 geographic distribution. 152 270 of. 274. 114. differentiation. hematoma hemiplegia 127. Paranoid dementia. 127. of. 279 treatment of. 142 symptoms of. changes sjinptoms. 285 circulation in. 284 eye-ground in. 143 in. appearance melanchoha. delirium delusions intercurrent. 156 in. 289. 136 275 differentiation. 159 senile. 105 dementia. 150 phantastic form. 289 changes in eye-ground in. 303 gold test. 140 predisposition to. 143 melancholia mystic. 275 secondary. 141. 288 period of persecution bone changes 150 persecutory phase.

138. 290 suicide in. 279 pachymeningitis hsemorrhagica 304 weight in. 274 pleocytosis in. rate. 50. in paranoia. Wassermann globulin test in. 281. 287 278. 294 in. 141 Perspiration in mania. 358. 302. 305. 272 paralysis of cranial nerves in. 312 muscular changes in. reaction in. 320 in. 318 Paroxysm of hysteria. susceptibility to. 279 pathology of. illusions of. 286 of. 444 288 Periodic insanity. 295 eye symptoms. 282 sensory. sexual. 444 tremor in. diseases sweating 287 247 . 276 neurasthenia and. Paranoia. 185 Pineal gland. 287 visceral symptoms. 287 Paretic dementia. 289 pain in. 282. in. speech disturbances. 289 strength in. 362 Pellagra. 290 respiration in. visceral. 276 sex frequency. 288 unsalvarsanized serum in. 289. 270 sure in. 286 tabo-. 324 302. 318 trophic disturbances in. 277 Phobias. 310 multiple cerebrospinal sclerosis and. rate of progress. 288 treatment of. 265 transformation of the. 335 Pederasty. Parturition. 279. in mania. in. Nonne 302. 281 knee-jerks in. 56 of. 274 intraspinal pressure in. 280 lymphocytosis in. 150 of. 56 pseudo-. 270 Personality. juvenile. 282 skin in. 261 Partial insanity. 311 Pathologic idiocies. 302. double. 310 joint changes in. differentiation. 280. 363 of. 290 prognosis. 362 287 271 in. See also physical signs. 290 syphilis in etiology of. treatment in. sway of body in. 303 prognosis progress of.474 INDEX Paresis. 86 Perforating ulcer of foot in paresis. 91 Perversion. 308 urine in. period 141. 278. 139. 303 optic atrophy in. 262- simple demented form. 259 duration. 277 tabes and. 303 malarial. 267. 267 Paretics. in hysteria. 267. perforating ulcer of foot 288 discovery of treponema pallidum in brains of. 276 treponema pallidum in brains 267. 99 saliva in. differentiation. differentiation. of. increased intracranial pres- symptoms of. 304. 210 mercury in. 267 in 270 pathology 294. 319 Ught reflex in. Paresis. 287 salvarsan 305-310 Persecution. 269 prognosis of. 282 physical. 211 remission of symptoms. seizures in. iodids in. 287 rest in Perception. 210 pulse pupils in. 149. 281 stages of. 271 290 temperature in. 293 Passive confusion.

193 impulses 45. 409 Psychoses.383 Pituitary deficiency. 255 treatment of. anxiety. 475 See also Hys- Psychologic interpretation of sj'uiptoms. 258. 267 Pseudo-paresis. hallucinations 225 prognosis of. See in dementia prsecox. 389. 212 treatment chloral. alcohol. 383 of paranoia. 455 in treatment. 237 morphia. 198 hysteria and. 322 in opium. in. 441-444 281 Hutchinson's. medinal. 233 441 324 mania. 402 of dreams. 311 392 Respiration in melancholia. 185 Psychosis. 279. 67 287 Psychanalysis. 236 cocain. 251 Repression of complexes. 113. 278. 219. 71 Pupil. in dementia Pregnancy. Restraint. afebrile. teria. Progressive general paralysis. paraldehyd. 281. treatment lead. 254. 455 fever. 327 Poisoning. 441-444 paranoia. 237 sulphonal. 434 Psychic aura of epilepsy. psychic. Puerperal delirium. 455. Korsakow's. 247 gland. in confusion. delirium 211 in.1 INDEX Pithiatism. 324 prsecox. 388. 32. in paresis. 412 Prodromata. 302. 441-444 in paresis. 456 warm bath Rheumatic as form of. diseases of. 227 of. 124 in dementia hallucinations prognosis. lead. 390 Rest cure in neurasthenia. physical. 227 treatment dementia pra?cox. Delirium. 252 impotence. absence of. in 287 224 Pulse-rate in melancholia. of. . in head injury. 278. 237 193 veronal. 387. 237 See also Raptus melancholicus. 74 Reduction of field of consciousness Precocious dementia. 246 Pleocytosis in paresis. Psychology of dementia pra. 124 as cause of dementia prsecox. 376 pain in melancholia. 54 Preventive treatment. 67 448 of paresis. 175. 397 of insanity. 303 Plumbism. 324 Pulse in mania. in neurasthenia. 2 1 211 sequelse of epilepsy. 224 delirium in. 320 Pyromania. 227 treatment of. light. psychic. Postfebrile delirium. 147 hallucinations of. 91 insanity.cox. 123 of. 251 of. 280. 108. in paresis. Argyll Robertson. 211 in. 220 225. 226 in. 71 in paresis. 251. 444 Restraining sheet. of epilepsy. absence prsecox. 280 also Dementia proeco-r. 178 in paresis. 251 epilepsy. 277. of epilepsy. 237 trional. 455 pack as form of. Psychalgia. 225 . 251 Rheumatism. 327 Puerperium. prodromata reflex. 434 Psychasthenia. 326 tendon. 403 Reflex. diflferentiation.

40 dementia and. 95 perversion. 432 Stupor. special. 32. 186 Specific febrile delirium. 24 Schizophrenia. differentiation. Speech disturbances 281 Spinal tenderness in hysteria. 346 delusion. 45 tiation. 351 symptoms. 421 in paranoia. 376 hallucinations in mystic paranoia. mystic paranoia. 312 Sitiophobia in melancholia. 175. 148 Self-accusatory form of paranoia. 35 melancholia. thyroid extract in. 71 312 in paresis. 132 Sexual abnormaUties. simplex. 34. '' prognosis of. 400 in etiology of special fears. 29 tion. 57. 253 entiation. in paranoia. 422 Smell. 39 course. 187. 358 deficiency. in melanchoha. 305-310 increase of. 44 etiology. 165 unpardonable. 131. 91 Serum. delirium tremens and. 124. 432 Salvarsan in paresis. fear of. 70 Sedatives in deUrium. 358 Stomach. 40 toxic dehrium and. 421 Skull. 347 Senses. of. 91 choha. 68 paresis and. 28. 363 trauma. 43 in paresis. 351 senile Soul weakness. in paranoia. 184 form of hypochondria. 257 Starvation in melanchoha. 408 Sclerosis. of. in melanSecretions in mania. open. interrelation. 25 dementia. in melan- 69 mania. 166 instincts in hypomania. differentia- 59 of. 56 and confusion. shape of. delusion in melancholia. 178. 110 155 in paranoia simplex.1 476 Sadism. 179 in neurasthenic-neuropathic in- symptoms. course 188 diagnosis 58 59 . unsalvarsanized. 142 with morphin in dehrium. differentiation. multiple cerebrospinal. 198 Spaces. in diagnosis. 263 senile melancholia and. mental disease 152 related to. 347. 287 INDEX Sight. 40 mania. 45 308 Sex glands in dementia prsecox. 203. Somatic affections. in in of. hallucinations of. 287 Scopolamin in delirium. pathology. prognosis. tiation. 73 SteriUzation sanity. 71 Skin in melancholia. differen- 45 in paresis. 155 Salt solution. 390. 363 disturbances in neurasthenia. 91 hypodermoclysis in melancholia. 375. catatonic stupor and. 243 lavage of. Stigmata of deviation and arrest in etiology of heboid-paranoid group. 414 for prevention of in- sanity. 206 Senile confusion. cancer of. differen351 acuteness of. 203 mania. differof epilepsy. 148 Sin. 361 Saliva in paresis. hallucinations cholia. of. paranoia. 345 SomnambuUsm in hysteria.

neuropathy. 128 in pellagra. 363 in pathology of paresis. 85. 313 ovarian. 314 Thyroid delirium. 79 Test.nosis of. 78 257 in insanity in childhood. 294. 111 etiology of paresis. 320 in. in hysteria. gland. 59 320 Tachycardia 180 in neurasthenia. symptoms 60 treatment of. 147 425 simplex. differentiation. Tabes. hypomelancholia. 60 without delusions. 28. 244 desiccated. 71 in paresis. 341 207 310 dementia precox. stupor and. definition 23 of. 302. 17. 439 in sexual deficiency. of.INDEX Stupor. in paresis. Lange's colloidal gold. 290. 91 in melancholia. etiology of. differentiation. 59 Temperature differ- in mania. 444 ity. Suicide in arteriosclerosis. 259 inguinal. 195. 87 Thrombosis. Symptoms. 287 in specific febrile delirium. entiation. 19 psychologic interpretation 383 Syphilis. prevention 428 196 paranoid dementia. 106 as result of stupor. 477 of inherited hypodermoclysis in 57 treatment Sj^hilis in production of. of. 56 melancholia. in 304 mental. 332 in epilepsy. 60 425 Taboparesis. 70 in paranoia. 288 Tenderness. Taste. 243 . 398 in neurasthenic-neuropathic insanof. 413 Systematized delusion. association. 253 in hysteria. 28 of. 267 295 extract in neurasthenic insanities. 304 Thoughts in mania. 61 and. 243 prognosis of. in paresis. 54 Terminal dementia. 319 60 differ- tabes and. Suggestion in production of symp- 257 257 toms in of hysteria. 30. 277 42 of. stuporous melancholia and. GO com'se of. 319. symptoms nourishment prognosis simple. in feeble-minded chil- dren. diseases of. hallucinations cholia. in in Nonne's globulin. in melan- terminal dementia of. 61 paresis and. 303 Wassermann. in cretinism. for repressed or submerged comi")lexes. inframammary. 319 proe. in hysteria. cerebral. 318 ameboid pupil taboparesis 319.8. Sweating in paresis. 302. 211 Sulphonal intoxication. 454 in childhood. in paresis. in hysteria. 57 as result of. 237 Surgical treatment. 257 spinal. in hysteria. 60 Stuporous insanity. in. 320 differentiation. 341 Sway of body in paresis. entiation. 72 Tendon reflexes in confusion. 165 with excitement. 261 incomplete. 331 in melanchoUa.

of foot. 322 323 sexual. 155 148 simplex. 130 Verwirrtheit. 24 Uremic coma. 421 intoxication. in Tumor of brain. . 239 in mania. 287 188 Traumarbeit. 451 extramural. 241 Visceral hallucinations in paranoia. 208 Wahnsinn. 455 in afebrile delirium. 124 insufficiency in INDEX of. 70 symptoms in hysteria. diseases of. 39 192 Tics. Verdrangung. 237 with sulphonal in dehrium. forms of. 453 massage in. 24 treatment of. in paranoia. 439. 315-318 Typhomania. 190 Ulcer. 139 acuter. 420 455 pack as form of restraint. 286 Vision. 144. 28. 395 Treatment. symptoms. 192 treatment. cholia. 321 in. 147 signs of melancholia. sis. 413 confusion Warm bath. 444 Tremor in paresis. in paresis. differentiation. 400 confusion dehrium in. 454 intramural. 237 Verrucktheit. 276 Verbigeration 122 in dementia prsecox. enlargement dementia prajcox. 257 of paresis. 288 Unpardonable sin. Trauma of head. delusion in melancholia. specific febrile delirium and. 315 in. 139 acute. 412 bathing in. 69 in 318 Trional in delirium. in pare- of. 308 Unsystematized delusion. discovery in brains of paretics. definition of. 71 in etiology of special fears. mystic paranoia. hallucinations hysteric 317 in. 421 Trophic disturbances in paresis. 451 preventive. 187. 396 Traumverschiebung. 440 in insanity of deficient inhibition. 209 euphoria in. 165 288 Tuberculosis. 130 in. 452 as form of restraint. 455 surgical. 45 Transformation of the personality. hallucinations of.478 Thyroid gland. Treponema pallidum. in melanof. 267. 448 restraint. 393. 412 rest in. 241 Urine in diabetic coma. 396 Veronal intoxication. neurasthenia- symptoms 318 neuropathic insanity. 91 in melancho'ha. 417 full feeding in. 445 luminal sodium in. 390. 141 68 in Unsalvarsanized serum paresis. 448 hypodermoc lysis in. 440 Toxic deUrium. 422. 49 Viscera. 184 Tic convulsif in insanity of deficient inhibition. perforating. 209 in production of inherited neuropathy.

deficient. 111 in paresis. Wet pack 420 302. reaction in paresis. 304 Will. 316 Worry in melancholia. 196 Weight dementia praecox. 267.INDEX Wassermann in 479 in afebrile delirium. 190 . 287 rest cure. 71 Weir Mitchell 434 ZWANGSNEUROSE. Witzelsucht. insanity of. 66 loss of. in melancholia.



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