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CLINICAL PSYCHIATRY

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CLINICAL PSYCHIATRY

FOR STUDENTS

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PHYSICIANS

SACTED^AND ADAPtED^FROM THE XTH GERMAN EDITION OF

KEAEPELIN'S

VCeHEBU(WdER PSYCHIATKIE

A.

ROSS DEFENDORF, M.D.
IN

LECTURER

PSYCHIATRY

IN

YALE UNIVERSITY

"Nebs gorfe

THE MACMILLAN COMPANY
LONDON: MACMILLAN &
1904
All rights reserved

CO., Ltd.

Copyright, 1902,

By

THE MACMILLAN COMPANY.
May,
1902.

Set up, electrotyped, and published
April, 1904.

Reprinted

"RC-t54 904 K

NortonaB $rt«s
J.

S. Cashing

& Co. — Berwick & Smith Co. Norwood, Mass., U.S.A.

PEEFACE
The motive
for this

work was

to

make

the teachings

of Kraepelin in psychiatry accessible to

American medical

students and general practitioners, and, at the same time,
to provide a full, but concise, text-book, not only for the

author's

own

classes in psychiatry in the Medical Depart-

ment

of Yale University, but as well for other American teachers who follow Kraepelin's views. Urged by

the rapidly increasing interest in Professor Kraepelin's

teaching during the past five years in this country and
the constantly growing number of his disciples,
the author's
first
it

was

intention to publish a complete translation of the sixth edition of Kraepelin's " Lehrbuch der

Psychiatrie."
lation

It

was

feared, however, that a full trans-

of a text-book,

would be too large to best subserve the function and would have rendered impossible the

adaptation of the Kraepelin psychiatry to our peculiar

American needs. The classification, terminology, and, wherever possible, the phraseology of this work are Kraepelinian, but the
author has taken the liberty of abbreviating dispropor-

some psychoses which are of less importance to the American physician, especially the constitutional psychopathic states and thyrogenous insanity, and of laying more stress upon other more importionately the description of

tant

forms,

the

description

of

acquired

neurasthenia,

traumatic neuroses, also the treatment in epileptic and
hysterical insanity

and acquired neurasthenia.

He is particu- larly indebted to Dr. Ph. August Hoch and Adolf Meyer for their continued inspiration and of the text as well as for the critical assistance.. CONN. especially Dr. and the author begs leave to express in this place his grateful appreciation of the generous advice and help of his colleagues in the hospital. and treatment in the first volume of Kraepelin. to Professor Raymond Dodge. Page. MlDDLETOWN. and treatment of the different diseases.. for criticism and suggestion with regard to the general symptomatology. January 15. diagnosis. diagnosis. of Wesleyan University. and to Dr.vi PREFACE The only omissions are the general etiology. J. The work has been done in the pressure of routine duties as Assistant Physician and Pathologist of the Connecticut Hospital for the Insane. but such points as are of most importance have been added to the etiology. ROSS DEFENDORF. M. Keniston for a general revision arrangement of the chapter on epileptic insanity. 1902. A.D. . Charles W.

disturbances of the rapidity of thought. polyneuritic psychosis (Korssakow's disTreatment. disturb- ances of judgment and reasoning. Diagnosis. delirium of smallpox. vii 90 Symptomatology. 73 74 Course. Symptomatology. Course. Infection Psychoses A. disturbances of the formation of ideas 18 and concepts. Initial deliria. and hydrophobia. typhoid. nosis. Treatment. Disturbances of Mental Elaboration Disturbances of memory. Prognosis. Diagnosis. disturbances of capacity for mental work. Simple asthenia. Prog- Treatment. stuporous form. 76 Symptomatology. B. Etiology. Collapse Delirium Etiology. disturbances of self-consciousness. . Prognosis. Psychoses Characteristic of the Post-febrile Period of Infec- 79 Symptomatology. Symptomatology. Disturbances of Perception Hallucinations. Disturbances of the Emotions D. Disturbance of Volition and Action 46 56 FORMS OF MENTAL DISEASE I. II. delusional form. clouding of consciousness. Treat- B. disturbance of appre- 3 hension. Exhaustion Psychoses 85 85 Course. Prognosis. B. Treatment. disturbances of the train of thought. Acute Confusional Insanity (Amentia) Pathological anatomy. Course. Infection Delirium Pathological anatomy. C. tious Diseases C. A.CONTENTS GENERAL SYMPTOMATOLOGY PASS A. Fever Delirium Etiology. ease). ment.

. Acute cocain intoxication. Diagnosis. Symptomatology. Etiology. IY. Course. Diagnosis. Chronic cocain intoxication. B. Cocainism intoxication. Symptomatology. Symptomatology. C. nosis. omy. Course. Course.viii CONTENTS PAGE Chronic Nervous Exhaustion . Acquired Neurasthenia. 141 Etiology. B. V. Diagnosis. Symptomatology. Cretinism Etiology. Diagnosis. Cocain delusional insanPrognosis. Diagnosis. Chronic Intoxication 1. Symptomatology. Course. Treatment. 146 146 Course. 134 Pathological anatomy. General symptomatology: Disturb- ances of apprehension. disturbances of judgment. Acute morphin morphin intoxication. ProgTreatment. 152 Treatment. disturbances of memory. lead. Treatment. Thyroigenous Psychoses A. Prognosis. Treatment Alcoholic 126 Paranoia: Symptomatology. Pathology. disturbances of attention. 149 Pathological anatomy. Prognosis. Myxoedematous Insanity Etiology. : 129 Symptomatology. Sympto: : 107 110 115 matology. Treatment Alcoholic Delusional Insanity: Etiology. Pathological anatomy . Course. 2. Treatment Alcoholic Pseudoparesis Diagnosis. Prognosis. chloroform. Diagnosis. Alcoholism 107 107 : Acute Alcoholic Intoxication Pathological anatomy Pathological anatChronic Alcoholism Etiology. hallucinations. : 96 105 105 atropin. Course. 3. disturb- . 131 Morphinism Etiology. Acute Intoxications Organic and inorganic substances santonin. Prognosis. omy. Treatment. ity. Course. disturbances of thought. disturbances of consciousness. Dementia Prsecox Etiology. Treatment Pathological anatDelirium Tremens Etiology. . Chronic Abstinence symptoms. ILL Intoxication Psychoses A.

Symptomatology. Treatment . physical symptoms.. Encepha250 subcorticalis. Paranoid Forms. Multiple sclerosis. Expansive Form. Physical symptoms. course. First Group. Agitated Form. Thrombosis. course. Demented Form. Abscesses. Treatment. Senile Course. disturbances of emotions. disturbances . Treatment. Head injury. disturbances of consciousness. Diagnosis. physical symptoms. Second Group. disturbances of memory.. 282 General symptomatology: Disturb- Treatment.. Pathological anatomy. Prognosis. disturbances of conduct. 249 Diffuse cerebral sclerosis. Arterio-sclerotic tary syphilis. Dementia Paralytica Etiology. ances of apprehension. physical symptoms. anatomy. special symptomatology. Heredi- 225 241 249 VII. hallucinations. Localized Lesions Tumors. IX. litis insanity. Pathological B. Etiology. disturbances of consciousness. C. outcome Catatonic Form Pathological basis. Manic-depressive Insanity Etiology. Involution Psychoses Insolation. 254 254 Course. Diagnosis. disturbances of conduct. delirium. De- pressed Course. Presenile Delusional Insanity Symptomatology.CONTENTS ances of emotion. outcome First Group: Special symptomatology. Treatment 188 196 203 VI. Treatment. Etiology. hallucinations. Diagnosis. Physical symptoms. VIH. Organic Dementia A. B. delusions. ix FAOS Hebephrenic Form Special symptomatology. Embolisms. 267 Diagnosis. physical symptoms. course. Prognosis. Special sympphysical symptoms. Hemorrhages. Senile Dementia Pathological anatomy. A. disturbances of judgment. General symptomatology: Disturbances of apprehension. disturbances of thought. Prognosis. course Diagnosis. Melancholia Etiology. Pathology. 273 Symptomatology. Senile confusion. Simple senile deterioration. disturbances of thought. Second Group : 162 173 : : tomatology. disturbances of capacity for mental application. Prognosis. Diffuse Lesions Gliosis of cortex. Form Diagnosis.

dreamy states. Symptomatology. pre- transitory periodical Symptomatology: Epileptic deill-humor. Prognosis. Impulsive Insanity 378 378 382 389 Xm. Prognosis. Compulsive Insanity Symptomatology. epileptic stupor. Congenital Neurasthenia Etiology. Prognosis.. dreamy and post-epileptic insanity. Treatment. Prognosis. anxious delirium. D. Treatment. conscious delirium. 291 Simple Retardation. Treatment . Treatment. Course. 329 Pathology. Paranoia Etiology. retardation. B.. Traumatic Neuroses Diagnosis. 371 C. . Diagnosis.CONTENTS PAOX of emotions. Symptomatology. Defective Mental Development A. XII. Hysterical Insanity Pathology. Course. pressure of activity. Stuporous Conditions Mixed Course. Diagnosis. Delusions and Hallucinations. 353 B. Symptomatology: Psychical symptoms. 406 Pathological anatomy. disturbances of conduct. Treatment. Treatment. Course. moral imbecility. General Neuroses A. pressure of speech. Treatment. dipsomania. Diagnosis. Maniacal States : Hypomania. Pathological anatomy. Course. Physical Symptoms. 299 305 307 316 X. physical symptoms. Symptomatology. Diagnosis. Contrary Sexual Instincts Etiology. Prognosis. Constitutional Psychopathic States A. Imbecility Symptomatology Stupid form. Diagnosis. psychic epilepsy. Symptomatology. Stuporous Mania Prognosis. . Prognosis. Etiology. Symptomatology. . . States : Maniacal Stupor. C. Symptomatology. : Mania. Etiology. states. active form. Idiocy Etiology. Delirious Mania .. Treatment. terioration. Prognosis. Course. Treatment. Retardation with Depressive States . : 392 397 397 B. Diagnosis. Querulent Insanity. Treat- ment. Epileptic Insanity Etiology. Diagnosis. Course. 329 XI. Treatment.

tension in catatonic stupor producing "Snautz- 176 2. 1. 180 182 Catatonic writing 4. 222 222 224 226 279 Fig. 8. . 11. . . Paretic handwriting Paretic handwriting Senile handwriting Plate Plate 9. Macrocephaly Microcephaly Casts of symmetrical and asymmetrical palates . 3. Muscular krampf" Plate Plate Fig. . 2. . Muscular tension in catatonic stupor Cerea flexibilitas in catatonic stupor 178 3. cerebral cortex in idiocy and dementia paralytica ence of spider also the glia in the normal cortex. Plate Plate Fig. the pres- cells in dementia paralytica and their relation with 210 the blood-vessels Plate 6. The normal cerebral cortex . . Plate 411 . . Fig. 220 222 . and the cytological changes occurring in dementia paralytica 208 Plate 5. Paretic handwriting Paretic handwriting showing partial agraphia Paretic handwriting showing complete agraphia 7. illustrating the lack of expression in the countenance and the inelastic attitude Fig. Plate Illustrates the normal pyramidal cell of the cerebral cortex . 406 408 10.ILLUSTRATIONS FAOIKO PAGE Plate 1. 5. A group of paretics. 4.

.

GENERAL SYMPTOMATOLOGY .

.

on the contrary. Loss of sight is tant. is of great importance indeed. for instance. In conditions of mental disturbance.GENERAL SYMPTOMATOLOGY A. according Such senas it stimulates the corresponding sense organ. but loss of hearing. Inadequate stimulation of the sense organ produces impressions corresponding to the " specific energy " of that sense . but they do no harm because they are immediately recognized as illusions. development in proportion to the importance of the senrelatively unimporits sory material lost and the possibility of substituting other sensory experience. DISTURBANCES OF THE PROCESS OF PERCEPTION perception of external : The sensory stimuli depends upon two conditions the adequate stimulation of the sensory end organ and the elaboration of this stimulation by the central nervous system. trained. deaf mutes remain mentally weak through Illusions and Hallucinations of sensory ex- More important than the mere absence perience is its falsification. sations are real illusions. especially 3 . unless specially life. relation to language. a tactual or a visual sensation. on account of . The loss of one or more of the senses modifies mental . a taste. an electric current may produce a sound.

they are often extremely vivid and misleading. noises. and. States of consciousness similar to sensory perceptions may be produced by the excitation of tbe so-called cortical naturally referred to an external an illusion as to the real source This group of hallucinations may be of the stimulus. In morbid conditions. or if an emotional condition temporarily . may be interpreted as where there fire or torrents of water. Because of their central origin. They have a fairly uniform content. seem to the patient to belong to the external world. which lead to sense deceptions. as hypnogogic hallucinations. This is and results in to slight modification (stable hallucinations of Kahlbaum) and consist of senseless words. figures. They may occur in normal called perception phantasms. They usually bear no relation to the content of thought. account of its This sort of peripherally con- ditioned sense deception has been called elementary. object. In abnormal conditions. which are repeated over and over again. Peripheral influences may directly. In other cases. on origin in that part of the sensory apparatus which receives the stimulus. particularly at the onset of sleep. and the like. subject only sensory areas. particularly if the general irritability of these parts is increased. ordinary organic stimuli suffice to produce such falsification. giving rise to genuine deceptions which are not corrected. directly or in- the peripheral sense organ and the afferent nerve. 4 GENERAL SYMPTOMATOLOGY is great clouding of consciousness.. or a roaring in the ear. individuals. conditions of excitation in the higher portions of the sensory tracts. the subjective sensations of light as the result of congestion of the eye. consequently. these hallucinations may appear if attention is merely directed to that sensory field. they may occur after destruction both of also produce.

They depend on the same sort of cerebral processes as does normal perception. and the production of alcoholic delirium sight in eyeball. entotic noises. are pure hallucinations. etc. universal characteristic of the entire group of sense their sensory vividness. when everything The deceptions is is quiet. Sense deceptions are divided clinically into hallucina- and illusions. conditions of stimulation in the sense organ found in the occasional occurrence of one-sided hallucinations. by gentle decep- pressure tions on the Usually single these sense appear only in a sensory field. curses and threats in ringing bells. are evidently illusions. The perception of ghosts in moving clouds and limbs of trees. change Further evidence of cooperation of is of environment. ficult to are falsifications of dif- In some cases this distinction may be carry out on account of internal stimulation of the sense organs. and feel. but they really see. etc.DISTURBANCES OF THE PROCESS OF PERCEPTION increases 5 It the general susceptibility to stimulation. the frequent association of chronic middle ear disease with hallucinations of long hallucinations of standing. hear. In other cases the distinction is clear. real percejits. believe that they see. as soon as the patient his becomes quiet in conversation. hear. In the the former latter there are no recog- nizable external stimuli. But the well-known and the voices which visual disturbance of the alcoholic. as manual or mental employment. or directs attention elsewhere. torture the condemned in his prison. such as occurs in phosphenes. and feel. . on the other hand. disappears. and the false perception takes its place in consciousness among the normal sensory impressions without any disThe patients do not merely tinguishing characteristic. and are most frequent tions in the fields of hearing and sight.

the lighter the reflex . This of a perception.. being regarded by Many the patients as real perceptions of a peculiar kind. but that only when the process becomes morbid. from hallucinations. there Probably moreover. not but only certain groups of ideas and besides these are usually ideas of the ordinary. the greater their irritability. 6 GENERAL SYMPTOMATOLOGY In morbid conditions very vivid ideas or memory images may assume the form of hallucinations. and formThe element which makes a hallucination out less type. a definite relation between the strength of the reperception and the irritability of the sensory areas is. some special cause must be present. is indicated by the fact that in patients suffering all. in it is easy to see the how they may participate varying degrees in active process of renewing view of this sort would explain the fact that there lies between the sense deception of pronounced sensory vividness and the most faded memory image an unbroken series of transition stages. It is posprevious impressions. faded. If it is really these areas of the brain through whose excitation perception acquires its peculiar sensory marks. through which alone normal stimuli come to consciousness (the so-called " reperception " of Kahlbaum). seem to play a role in the sense deceptions. that during the ordinary thought processes this reflex excitation or reperception is always present in a very sible A slight degree. the more easily will the memory images attain sensory vividness. does the vividness of the memory picture approach that of true sense perception. of a vivid idea is probably a reflex excitation of those central sensory tracts. be should perceptions false all investigators hold that regarded as ideas of imagination of extraordinary sensory But in order that an idea attain the clearness vividness. or the sensory areas themselves are in a condition of increased excitability.

every idea is followed by a distinct sensory after-image. usually belong to a single sensory and are independent of the train of thought. sometimes when writing. on the other hand. pseudohallucinations (Hagen). is In these cases not increased.e. when linguistic ideas come vividly The sensory after-image disappears to conif the . the patient has another distinctly subsequent idea of the same thing i. in close relation to the other contents of while the true falsifications of perception. but merely ideas of great it is By careful investigation often possible to analyze the data given by the patient. This double thought occurs most frequently when the patients are reading. involves several or the sensory and that it always stands consciousness . and occasionally. and to discover that the patient does not regard the impression as objectively real. which has been variously designated as psychic hallucinations (Baillarger). . The extreme case in the other direction would be those instances which are local excitation. tract. also. and the 7 more indepen- dent they are of the current of thought. and apprehension all of hallucinations fields. probable that the reperception strongly developed. but merely differentiates it from his ordinary ideas it is on account of its forceful vividness. A striking illustration of this type of hallucinations is found in a condition called " double thought. which apparently indicated hallucinations. not true sense deceptions at sensory vividness.DISTURBANCES OF THE PROCESS OF PERCEPTION excitation need be to release them." Immediately upon the appearance of any idea. all. sciousness. while irritability of special sensory tracts is This seems to be borne out by the fact that this group of hallucinations. The extreme case would be found in the sense deceptions depending upon which seem to the patient to be something quite foreign and external. (Kahlbaum).

activity of the imagi- and finally. the most tranquil scientific observer is Even never quite certain his investigation that his perceptions do not unconsciously suit themselves to the views with which he approaches while in reading of the type-setter we all unconsciously correct the errors from the residua of our experience. frequent occurrence in normal life prejudice. the inability to sift and correct experience by reason. all are favorable to its development. words are actually spoken. even in spite of our earnest effort to be neutral. A which. continually influence our perceptions . of a thoroughly falsified apprehension of the external when there are no true hallucinations. expectation and the emotions. even sions are confused tiated.." sensory stimulus may produce conditions of excitation. — frequently happens that the sensory impressions of patients take on fantastic forms and become the basis it Thus. Marked emotional excitement. giving rise to They are of very a distorted and falsified impression. In mental disturbances the conditions are often extraordifavorable for this falsification narily of apprehension. occasion the development of an hallucination. Similar conditions . normal and abnormal and There is states. 8 GENERAL SYMPTOMATOLOGY Other hallucinations of hearthis condition. This phenomenon naturally occurs most frequently. transferred to an over-excited sensory area. great nation. ing universally accompany Apperceptive illusions are those in which subjective elements unite with the objective sensory data. both in world. when the sensory impresdifferen- indefinite. and not readily group of disturbances which consists in the release of a false perception in one sensory field through a real impression received by another. constitutallied an ing the so-called " reflex hallucinations of Kahlbaum.

explanation is found rather in the intimate connection between the illusions and the patient's innermost thought. ditions these of In morbid con- may be very marked. morbid fears. especially in the end stages of dementia prsecox. and desires. of a mental disease the illusions are often recognized as such. This influence of the emotional life upon the thought and . also. It is frequently observed. sions feel very important characteristic of sense deceptions. and hallucinations overpower the judgment. is the poiverful entire and irresistible influence which they exert over the thought and activity of the patient. as well as at the end. as one might expect from their influence in normal life. that at the beginning.DISTURBANCES OF THE PROCESS OF PERCEPTION 9 are daily encountered in the so-called sympathetic sensations. but usually sound . There are patients who on their tongues the words spoken by others. The basis for this irresistible influence is not to be found persistent illusions in the sensory vividness of the illusion. like the unpleasant sensation of an inexperienced onlooker at a painful surgical operation. which in one way points to their origin and in another to their importance as a disease A symptom. while they completely disappear in the interval. Especially sensations movement which frequently accompany sense impres- seem to rise in this way. because of their improbable content. a glance from some one may excite a sensation of strain. and ultimately the patients invent the most foolish and fantastic explanations to account for them. since real sensaIts tions and definite evidence are useless as correctives. It is true that occa- sionally a pronounced illusion appears in persons mentally and. The emotional states and the feelings color the illusions in a peculiarly high degree. that illusions appear only in connection with the periodical vacillations of the emotional state.

The less . the emotional state. and the like. act as the real causes of delusions. No healthy individual would refer to himself such words as " That his attitude is the president. but that they express In view of these facts we see no special practical value in distinguishing in single cases whether the delusion. In both cases the illusions may continue. The most frequent sense deceptions of sight are those which occur at night." and then immediately believe he be the president. In the vast majority of cases. Illusions and hallucinations present a large number of clinical types in the different sensory fields. and especially where the sense deceptions appear with persistent delusions. . wild animals. patients point to their hallucinations as the basis of their symptoms. not and immediately there the truth. To be sure. all of these disease symptoms are certainly only the result of one and the same common cause. or even frequently. stone of tion of must But when these words form the keya long chain of secret misgivings. or when progres- sive deterioration obliterates emotional activity. an hallucinathat sort makes the most profound impression. or the corresponding sense deceptions appear first. toward his illusions In reality the patient's attitude and hallucinations is not the same as toward his actual perceptions. distorted figures. but there can be no doubt that the sense deceptions have a common mental source of origin with the other disturbances of the equilibrium. only that the words were really spoken. angels.10 GENERAL SYMPTOMATOLOGY actions only disappears with recovery. but the patients do not react upon them. the so-called visions God. dead persons. These facts manifestly disprove the general view that sense deceptions regularly. arises a firm conviction.

though occaenough to drown all other noises. Auditory sense deceptions are seldom indifferent to the . more even than real speech. in Sometimes there are several the barking of dogs. consist of pleasant music and songs. The basis for their importance lies in the fundamental significance of language in our psychic life. seeming to have a definite relation to the pulsations of the carotid. they are the linguistic ex- pressions of the patient's inmost thought. they are low. as It sionally they are loud coming from a distance. etc. in fact. Auditory sense deceptions but sometimes they usually occur in the form of loud shouting and cracking noises. tell his The voices secrets. In some cases there occurs a peculiar rhythmical rise and fall of the tone. The voices usually have an intimate relation to the con- tent of consciousness . mock the patient. a term which is usually well understood by the patient. are making grimaces. 115). Usually distinct " voices " with characteristic differences. interrupted remarks. and They are heard in the scratching of a pen.DISTURBANCES OF THE PROCESS OF PERCEPTION 11 common like sense deceptions of sight which appear in day- light along with the normal impressions are much more normal perceptions and consequently more deceptive. and for this reason have for him a far greater convincing power than all other sense deceptions. etc. threaten him. rarely happens that the "voices" speak long senif tences. ringing of bells. The objects of the surroundings may take on an entirely different appearance . patients mistake strangers for relatives and vice versa. wild shrieks . and believe that the same persons are taking on different forms and faces. The most important sense deceptions of hearing are the so-called voices. Usually they consist of short. sense deceptions of the alcoholics are of this type The (see p.

and volitions. excited. angry attacks on their " suggestions. phoning." " tele- The so-called " internal voices. Sense deceptions in the other senses are of importance. form a special group of These naturally are not regarded by the patients as sensory in their origin. or that they are produced and influenced by outside forces. They make them to distrustful. with distant persons sometimes the voices of conscience seem to are criticise the patient or spur him on. is This present experience designated as consciousness which whenever physiological stimuli are converted into psychic ." hallucinations of hearing. muscular. and not from the disturbance of the sense organs. dermal. and general senses. False perceptions of taste. but almost always a severe disturbance of the higher psychical processes.. of position." " telegraphing. so far as they derive their origin from the thoughts of the patient. are present we no longer have simple illusions and hallucinations. of incasement of different organs of the body. and even drive them imaginary tormentors. point to a profound change of the whole psychical personality. Where delusions of electrical influence. etc. the disappearance of the ears.12 patients. In all these cases the patient develops the delusion that his thoughts known to every one. They may occur as a kind of monologue or as a conversation . but GENERAL SYMPTOMATOLOGY are almost always accompanied by strong influence emotional disturbances and wield a powerful over the patients' actions. is feelings. much less smell. mouth. Clouding of Consciousness External stimuli occasion within us characteristic mental phenomena which we apprehend immediately and guish as distin- presentations.." etc.

but as yet undetermined. yet we know not depends upon the funcits tioning of the cerebral cortex. clear only and distinct when they find residua of past . Disturbance op Apprehension The vast majority of our impressions at any given Presentations moment become are obscure and confused. aroused by external stimuli. Whether such is transformation takes place in individual cases often very difficult to determine. thus possible to distinguish different degrees of the clearness of consciousness according to the character of the threshold But even when conscious processes are no longer value. physiological processes in the nervous system. and are compelled draw our conclusions from The condition in which the transformation of physiois logical into psychical processes completely suspended. is so the condition of the cerebral cortex the determining factor in the transformation of physiological into conscious processes. This limit is called the threshold value and varies greatly according to the condition of the cortex. Just as the transition of the external stimuli into sensory excitations depends upon the nature of the sensory organ. is designated unconsciousness.DISTURBANCES OF THE PROCESS OF PERCEPTION processes. but also that individual phenomena are connected with definite. since insight into the inner experience to we have no immediate of others their behavior. the threshIt is old value reaches infinity in the deepest coma. 13 The nature only that it of consciousness in general is obscure. consciousness in the form of obscure presentations and general feelings may still exist. process Every stimulus which crosses which cannot sink the threshold of consciousness thereby arousing a psychic must possess a certain intensity below a definite limit. While it is lowest in strained attention.

" resonators. We When the memory residua respond only to intense stimuli. " Wundt calls apperception. and amentia. Thus the details of an inverted landscape are largely lost to us. this condition passes over into insensibility and lethargy. residua of previous experience fail Whenever the prehended . Ordinary fatigue and is its transition into sleep present all degrees of this phenomenon. epilepsy. which lation is intensified. . external impressions can be understood only occasionally and with still effort. Lesser disturbances of appre- hension are encountered in manic-depressive insanity. is also found in the following morbid states : mental exhaustion. pression This supplementing the given imthe danger of a by memory images greatly increases the delicacy it of our apprehension. through which alone it can be understood. and there results a clouding of consciousness. external impressions are not com- the whole content of consciousness becomes less distinct.14 GENERAL SYMPTOMATOLOGY memory. Even if intense stimuli force their way into consciousness. such as alcohol. they are not understood." as it experience in the were. collapse delirium. and trional. fever and intoxication deliria. to cooperate in perception. as they have no connection with have a similar experience when we are confronted by absolutely unfamiliar circumstances to which our past gives us no clue." that each percept becomes united with our past experience. paraldehyde. although the sensory stimuli per se are quite as intense when inverted as when the past. right-side up. but brings with falsification of perception. A similar disturbance of apprehension produced by a number of It hypnotics. If the disturbance of apprehension is greater. through whose sympathetic vibration the sensory stimuIt is through this process.

The consciousness of the idiot nothing but an obscure mixture of isolated. in his environment in 15 which one its is unable to comprehend temporal and spacial relations and the personality of those about him. as in delusions. require Orientation seems to more elaborate mental processes than does the it understanding of isolated words. while the ability to understand ques- and orders is lost. On the other hand. In a child the content . 117).DISTURBANCES OF THE PROCESS OF PERCEPTION Disorientation. but the converse is not true. or grouping is possible. etc. in which neither clear apprehension. and is precisely these more elaborate processes that seem to be affected most in the moderate degrees of clouding of consciousness. is possibly a special form of a moderate clouding of consciousness. Normal consciousness during childhood experience is its development in earliest similar to clouding of consciousness. orientation may tions be fairly good. All of this naturally has no reference to the disorientation which is caused by false interpretation of impressions. lucid arrangement. The most striking example of this occurs in delirium tremens (see p. Defective orientation is always associated with disturbance of apprehension. confused presentations and indefinite feelings. But even when some impressions are well apprehended the disorientation may be more or less complete. The child lacks the complex is memory residua by which present interpreted. The causes of this disturbance are probably very complicated. The sions is possibility of active attention and choice of impres- the most important result of the influence of the memory residua over perception. It is self-evident that in coma one can no longer comprehend his environment. In the more severe forms of this defective psychical development condition remains is permanent.

while we apprehend with greatest acuteness the finest alterations in some special object. so that some stimuli. This attention is ability to concentrate the of the greatest importance for the development of the understanding. The extreme form occurs in tractibility is idiocy. yielding psychic processes. it receives only the upon accidental most striking stimuli.16 GENERAL SYMPTOMATOLOGY is of consciousness helplessly dependent circumstances . We train ourselves to notice certain impressions in prefer- ence to others. on the other hand. however faint. the less the perception is controlled by the inner motives arising from experience. Details are apprehended without a comprehensive view of their relation. of the attention distractibility. so that in the same moment strong stimuli pass quite unnoticed. the process of perception more and more dominated by personal tendencies which gradually develop out of the experiences of the individual. A in lesser degree of dis- found in the absent-mindedness of fatigue. them no view. by accidental external The greater the distractibility. The domination is influences called Individual percepts are linked incoherently with those internal associations which are developed under the inof controlling ideas. is Distractibility more marked chronic nervous ex- haustion. and the entire apprehension is superficial. during convalescence from severe mental and . is In adults. On the other hand. we accustom ourselves to be inattentive to regularly re- curring stimuli. have decided advantage over others. and the less coherent and uniform is the conception of the external world." definite leads to an extraordinary variability of the threshold of consciousness. of over our This development of definite " points influence directions of interest. This defect is found in fluence children and more or less in some normal adults.

and still 17 more prominent in the acute exhaustion psychoses. also in paresis and dementia prsecox. In these conditions a single stimuli suffice to distract the word or the most casual attention. while it is especially characteristic of maniacal forms of manic-depressive insanity. and the complete absorption of the melancholiac in his sad ideas. ." which consists in the total absorption of the attention by a single process. examples of which are found in the so-called absent-mindedness of scholars.DISTURBANCES OF THE PROCESS OF PERCEPTION physical illness. Distractibility is not to be confused with " hyperprosexia.

DISTURBANCES OF MENTAL ELABORATION dif- The material of experience. to the multiplicity of interest it its relations to other processes. and it is self-evident that both disturbances of apprehension. its i. must affect of all a marked degree the character intellectual processes. forms a basis all for further mental elaboration. The residua are strong and permanent in direct proporto the store of experience tion to the clearness of the original impression. to the arouses and to the frequency of of our ideas repetition. mem- Every impression which has once entered consciousit ness leaves behind its a gradually fading " disposition " to which may be accomplished either through an accidental association of ideas or through an exertion of recall. and the inability to make a to systematic choice in the impressions. The vast majority association complexes with and the greater part of the which we have to do daily effort. . the will. dependent on impressi- and on each of which 18 may be disturbed > independently of the other.B.e. This disposition to recollection is really identical with the residua which each new perception contributes and to the resources of memory. received through the ferent senses and clarified by attention. Disturbances of Memory All higher mental activity depends largely upon ory. are so accessible to us that they appear of themselves under the least provocation and without any Memory bility is really a dual process retentiveness.

especially when aided by active attention.DISTURBANCES OF MENTAL ELABORATION 19 Impressibility is the faculty of receiving a more or less permanent impression made by new experience. and therefore out memory. and in the dementia prsecox and in epileptic insanity. manifested by an inability to accurately recall former knowledge and important personal events. Eetentiveness of memory for past events depends upon the previous impressibility. Lack of im- . while it is lessened by difficulty of apprehension. in which patients cannot remember the events which immediately precede injury. paresis. consciousness. many delirious " Retconditions. is It. and Korssakow's disease. and hypnotism. head and some attempts at suicide. increases this impressibility. therefore. Similar conditions of clouded consciousness. The clear apprehension of events." in which memory is more or less permanently destroyed without clouding of consciousness. impressibility diminished which renders it the greatly This demonstrates that difficult to recall our dreams. senile dementia. and paralytic attacks. with undoubted evidences of a psychic activity. rograde amnesia. to a extent in the absent-mindedness of fatigue. is diminished wherever there cloudiness of consciousness as in amentia. hysterical. profound intoxications. Memory for this period may return. can exist withpsychic life. especially those with extensive lesions. by distractibility and less indifference. occurs in epileptic. states of deterioration in of impressibility in many other diseases. which are characterized by stupid indifference There is also a marked disturbance to the environment. upon repetition and the native Its disturbance is tenacity of the individual memory. occur in epilepsy. although the moment impressions are In normal life it is well apprehended and assimilated. but yet without memory. the attack.

striking in senile ease and accuracy. the past is always more or Vivid imagination and pronounced egoism less falsified. Finally. persecutory and expansive delusions often it color the memory of the past until seems like pure invention.. which only recent events are remembered distinctly while the rest is grouped around more or less isolated points which form the basis for the general chronological arrangement of our experience. normal conditions. In morbid change of personality or the emotions. while remote events recur in memory with even more paresis. On the other hand. accuracy is only relative. This embellished with interesting becomes a more and more imporalways exaggerated in disease. . by In clouding of consciousness. and in the development of delusions. but is pressibility usually the converse affected is is not necessarily true. the image of the immediate past fades so quickly that it appears as remote as the events which happened months ago. and in the severer cases of senile dementia. 20 GENERAL SYMPTOMATOLOGY accompanies lack of retentiveness. as impressibility not. to whom months often seem like days. while retentiveness senility the former is far more disturbed than the latter. the in Even imperceptibly modify the in memory of past experience even normal life . This is dementia and may occur in Our experience in is usually retained in memory in a tem- poral series reaching back from the present into the past. recent events leave no residua. Disturbances of the temporal arrangement of experience are frequently encountered They are usually more or less proin mental diseases. while in melancholia. nounced in paretics accuracy of memory may be disturbed. stories are self is details. while the tant factor.

memory images of the past. being found especially in paresis. furnished normal life are composed by the various senses. tures A These are often fantastic accounts of wonderful adventhey may be modified by suggestion and are . Disturbances of the Formation op Ideas and Concepts Most of the complex ideas of of heterogeneous elements. while the accidental variations of each individual experience are driven more . so every event seems like a duplicate of a former This sometimes occurs transiently in normal it in disease may last for months. In these complexes the importance of the material furnished by any one sense depends upon the peculiarities of the individual. lack of permanence and imperfect assimilation always This is interfere with the formation of complex ideas. vision . The delusion of a double existence that may be produced by confusing present experience with indistinct experience. 215).DISTUEBANCES OF MENTAL ELABORATION 21 mixture of invention and real experience is called paramnesia. for others. illustrated in congenital and acquired imbecility. For some. and is found particularly in epilepsy. There also exist " hallucinations of memory " (Sully). life . audition but both of these senses may be entirely lacking without preventing a high develop- ment of ideation. and sometimes also in maniacal forms of manic-depressive insanity. paranoid dementia. frequently self-contradictory (see p. is the most important sense. of sensory impressions The formation of concepts is the necessary condition for the fullest development of ideation. On the other hand. In normal life those elements of experience which are often repeated impress themselves more and more strongly. which consist of pure fabrications.

i. and the tangible. But even these may not be reproduced in totality. but it also retards the assimilation of new material. In morbid conditions. concise essential They are unable to find . and general ideas and concepts are gradually replaced by the specific. More and more in the developed consciousness single elements of these concepts are made to stand for the whole. expressions is for more extended experience the not distinguished from the unessential. The concepts thus developed are a sort of composite photograph or generalization of experience. Later. the general from the particular. and pass rapidly into oblivion. highest form of this development is found in the abbreviation of thought by the use of linguistic symbols. Similarly in paresis. These concepts are the most permanent and most easily reproduced of all our ideational processes. This not only prevents the development of thought. this defect gradually becomes more evident. this development may stop at any point. the immediate. dementia praecox. especially in congenital imbeThe cility.22 GENERAL SYMPTOMATOLOGY and more into the background. when a word stands for the idea. the circle of ideas narrows. of earlier experience In acquired imbecility the residua may partly conceal the inability to receive new impressions and to form new ideas. however. as when some The single image comes to stand for the total concept. and senile dementia. New impressions find no life . patients may cling to individual experience without being able to sift out the general characteristics of different impressions of a similar nature.e. point of attachment in the mental they cannot be arranged or systematized. New impressions are no longer elaborated . is The exact form of this abbreviation of thought often accidental.

impossible plans and chimeras. The tendency to reveries and dreams. while memory of the past is still fairly constant. Disturbances of the Train op Thought The association of ideas may be divided into two groups : external and internal associations. This disturbance may in a morbid tendency to rhyme. as in quotations and stereotyped phrases. paresis. Sound associations. so often found in imbecility.DISTURBANCES OF MENTAL ELABORATION and the most recent experience the is 23 quickly forgotten. be so marked that the associated sounds are altogether meaningless. in which a definite association of the movements of the vocal organs. lack of appreciation of facts. words becomes so fixed by frequent repetition that one word always calls up the others. of which thunder and lightning is an example or through habits of . which can give rise only to one-sided and mistaken judgments as soon as the patients leave the region of immediate sensory experience. which correlates dissimilar and even contradictory ideas. are clinical forms of this disturbance. are based either upon similarity of sound or of speech. the former being effected by purely external or accidental relations. an important and extreme form of this type. and paranoid dementia. External associations usually arise through the customary connection of ideas in time or space. Such forced and arbitrary combinations naturally interfere with the normal development of concepts. for example. as seen. Thus the foundation of all higher mental activity becomes a mass of confused and indistinct psychic structures. while the latter arise from a real coherence in the content of the ideas. In direct contrast to this is the disturbance produced by morbid excitability of the imagination. .

It occurs in a moderate degree in fatigue. . the simplest form of disturbance of the train of thought. Narcotic poisoning presents severer forms. same class.24 GENERAL SYMPTOMATOLOGY Internal associations depend upon the logical arrange- ment of our ideas according to their meaning. : . which emphasize some particular characteristics of a concept. states of being. as fear. to which it In contrast to the paralysis of thought. presents a superficial similarity. by means of which a preceding idea is more closely defined. this inhibition may suddenly disappear under certain conditions. animal belongs to the that he second. is first class of internal associations . The most pronounced . or activities. is characterized by complete It begins as a more or less and develops into characteristic monotony and distractibility of thought. marked retardation. belongs to the Paralysis of thought. plete standstill. and senile dementia. The patients do not lack mental ability they are not. The special form of internal associations. usually attributes. It is a fundamental symptom in the psychoses accompanied by deterioration paresis. but they are unable to overcome this restraint which they themselves very often realize. is called predicative association. etc. The asso- ciation or different species of the between different individuals of the same species. Retardation of thought is manifested by difficulty in the elaboration of external impressions the train of thought is markedly retarded and the control of the store of ideas is incomplete. It may bring the train of thought to a com- absence of all associations. That the dog is an animal. obtuse and indifferent. like the weak-minded or deteriorated. is of this kind for instance. dementia prsecox. dark-colored. the association of boy with man and man with . or that he runs.

view which is borne out by our experience with the per- — . These are usually accompanied by a disagreeable feeling of subjection to some overwhelming external compulsion.DISTURBANCES OF MENTAL ELABORATION 25 form of this disturbance is seen in the depressed and mixed forms of manic-depressive insanity. and of the ideas which appear in consciousness. Out of the large number of possible associations those only really occur which lie in the direction determined by the general goal of the thought process. in the disturbance of thought in epileptic stupor. (cf. unaccompanied by marked unpleasant This phenomenon is probably due to the abideas. or other trains of thought with an especially prominent emotional tone p. and perhaps. In morbid conditions the train of thought may be inter- rupted by individual ideas. The of our disturbances of the content of thought are best understood as a faulty arrangement of the individual links thought with relation to the goal ideas. accompany melancholia. and especially depressed forms of manic-depressive insanwhile the most favorable condition for their develity opment is hereditary degeneracy (see Compulsive Insanity. a sence of definite or fixed goals in the train of thought. 260). Melancholia. They usually develop on a basis of emo- tional disturbance. The mere fear of their recurrence is often sufficient to bring them into consciousness. p. therefore. those elements are specially favored which stand in closest relation to these controlling goal ideas. Normal thought is usually directed by definite goal ideas. also. 382). . Distinguished from the compulsive ideas are the simple persistent feelings. Compulsive ideas are those ideas which irresistibly force themselves into consciousness. and.

repeat isolated words or phrases. or when they incessantly weave them into more One patient reor less incoherent trains of thought. daddy don't. Oh oh and oh I ain't going to stay here any longer. Oh oh oh drop Another repeated : " — — — — — — — — — — to you. and melodies thoughts. Catatonic patients present this disturbance especially during the period of excitement. In this way we come to depend upon a large number of phrases and fixed associations. but rather the entire mental condition. etc. New York City. peated for twenty-four hours." Oh oh oh We are the Wall look at the clams Streets of New York. Since the content of such persistent ideas is to our wholly accidental. — — — — — — — — — — — coming little your money in the racket. which inevitably follow the appearance of certain cues. Oh oh oh he ain't doing a thing but spending his money. Oh oh oh that we get on 33d Street. . Our whole mental development depends upon associations of ideas gradually fixed by frequent repetitions. but even against it. but are based on the fixed residua of previous experience. verses. whenever we give free Rhyme." will slot and you will get all that's Persistence of ideas in definite trains of thought ferentiated is dif- from compulsive ideas by the fact that in the former the ideas are not accidental. Oh Oh — oh — oh — he never get that — oh — oh — Yale College don't do a thing. Oh oh oh and I'm going home.26 sistence of rein GENERAL SYMPTOMATOLOGY some of our own ideas. sometimes cling to us even in spite of our efforts to throw them off. not only without our volition. ties of it is probably not the special peculiariits the individual ideas which determine persist- ence. " Daddy don't. Oh oh oh they got a big thing down there. which serve as a basis for further mental elaboration.

This results in a monotonous content of consciousness with a marked This occurs in impoverishment of the store of ideas. Frazier went for. These phrases in contrast to the persistent ideas of the catatonic are not senseless. it. paresis. processes. hunger. the place." etc. If I get well I will keep it. They won't stay in a place. if I can. The boys would like to have some farm. the little children will starve for hunger. an example " Frazier went away this morning.DISTURBANCES OF MENTAL ELABORATION 27 elaboration of In morbid conditions. Circumstantiality ideas is the interruption of the course of of a great multitude of non-es- by the introduction . will be back soon. Father . the children will starve for [Patient looks at her hand. but actually express the The following is content of the patient's consciousness. in senility. I have been out on the farm a good deal. in the lot : is talking of selling the place. [Patient hears a woman coming up If she If the hall. don't care for the farm. I He don't home much. Didn't ask him what time he'd come home. He asked me what me I cared about Father is going over there to-day. Frazier don't have time to work. would advise them to have a place and keep it. He didn't speak to he is downhearted.] Some woman I hear coming. or even a few words which are repeated over and over. and other deterioration which the train of ideas may shrink down to a few phrases. was on a farm. she sell wouldn't handle much I money. He should bring up his boys to work upon stay it. they the place. even when the collection and new impressions is prevented by mental disease.] am all blacked If he sells up. I was up Frazier is working up in the lot at something. Frazier don't like to work on the farm. I forget what I yesterday. there remain some residual ideas of the normal state. fixed by constant repetition.

or will sufficiently establish something or will speak in conformity with the truth. also marked degree : in epileptic insanity. and the relate further Emperor of Germany. showing some coherence. go through it yourself. I myself say. the thing is right or is not right. in The simplest form stantiality appears the prolixity of the uneducated. if one will make a statement about a thing. and show a tendency to Some even have difficulty in distinguishing sharply what is actually seen from what is simply imagined. then man can at once say the thing is beautiful or is not beautiful or not good therefore. 28 GENERAL SYMPTOMATOLOGY which both obscure and delay the The disturbance depends upon a defecimportance of the individual ideas sential accessory ideas. is beautiful or that a thing is not beautiful . probably due to the disappearance of the general ideas present to a which the following passage taken from the bibliography of an epileptic is an example " Before one believes what others have told him or what he has read in the almanacs he must be convinced and examine himself before one can say and believe that a Circumstantiality is and concepts. train of thought. but of circum- only after many detours.. of — thing then. and when man has investigated everything and has gone through it himself and examined it. be real ultimately obtained. The goal may. who are unable to arrange their general ideas in accord- ance with their importance. William the Second. the King of Prussia. The circumstantiality of the senile is adhere to details. first investigate. tive estimation of the in relation to the goal ideas. I will now what the soldiers have done to me." . indeed. so must every man likewise examine the thing as he believes himself responsible before the tribune God. and examine it. and before his Majesty.

the rapidity all increased. (2) desultori- The is of ideas first effect of a defective control over the train a frequent and abrupt change of direction. In flight of ideas the instability of goal ideas produces a condition in which the successive links of the chain of thought stand in fairly definite connection with each other. the rapid succession of ideas which . (1) flight of ideas. therefore. The impetus for such changes of direction can arise from both external stimuli and from internal processes. It may appear in alcoholic intoxication. As the result of this. The patient's incoherence. but constantly falls into new pathways which are immediately abandoned again. of ideas. then. because ideas once aroused are immediately forced into the background by others. but There on the contrary is it is no great wealth often accompanied by a is conspicuous poverty of thought. infection deliria.DISTURBANCES OF MENTAL ELABORATION 29 The absence or incomplete development of goal ideas gives rise clinically to two important forms : of disturbance of the train of thought ness. depends simply on the lack of that unitary oontrol of the association of ideas which represses all secondary ideas and permits progress only in a definite direction. and also occurs in acute exhaustion psychoses. paresis. and cannot be held to a problem requiring much mental work. not at but on the other hand is usually diminished. of the association of ideas Moreover. any accidental idea which inhibit the goal idea would normally tance. but the whole course of thought presents a most varied change of direction. occasionally also in fatigue of normal life and especially in dreams. The patient is unable to give long answers to questions. This is a fundamental symptom of the maniacal form of manic-depressive insanity. The train of thought will not proceed systematically to a definite aim. It is may assume impor- not.

giving rise to an incoherent progression of unrelated fancies. warrants the designation of a bility of single ideas but the insta- which are unable to exert any influ- ence over the course of the train of thought. is In flight of ideas the direction of the train of thought determined by external impressions. Come up with an old green are diverted : umbrella 'cause ary when there winter. cured hams. Butler was having dinner. is The which influence of chance ideas well demonstrated in intoxica- tion deliria. and especially in opium intoxication. it rained. asked when she left the Hartford Retreat) " My mother came for me in January. they butchered eight that made their own ?] and tried out their lard. This might be called the delirious form of flight of ideas. or finally by simple associations. in spite of many diversions.30 GENERAL SYMPTOMATOLOGY flight of ideas. twasn't Friday. chance ideas. he no Catholic. we see a fairly good sequence in the content of ain't ." Here. She lives in a little white house kitty corner of our'n. was raining like all get out. and incidents. The rambling thought of the hypomaniacal patient is another form of the flight of ideas in which the patients by unimportant ideas. reminiscences. just sat with his back to the door and talked and laughed and talked. and need to be frequently led back to their subThe following is an example (the patient being ject. She had on a black bombazine of Aunt Jane's. hog-killing time. Snow wasn't more than half sausages. to which experience offers no key. external or internal. an inch deep. One shoestring of her own and got another from neighbor Jenkins. in vivid ideas of the imagination follow each other in a variegated series. codfish. They had a smoke and it your leaving Hartford half-past eleven train [But how about She got up to Hartford on the house. Dr. is a You know it can rain in Januthaw.

I like west strawberries Rebels is don't shoot devils at night. if only the most external. until the original standpoint entirely lost sight of.. In phrases. . In desultoriness there is was no recog- nizable association between the successive ideas. which graduother aimlessly and abruptly. etc. but feet win the neatness of men. while sound associations. the sweet boy. ally led to a new chain. best. but west runs east. and internal associations. the predominance of motor speech ideas has led to a massing of habitual speech associations. rhymes. form of this type of incoherent speech. Run don't run west. while the external form of speech fairly well retained. the second an increased motor excitability and alcoholic intoxication. on the other hand. stifle all The most is favorable condition for the appearance of this form Desultoriness.DISTURBANCES OP MENTAL ELABORATION thought which centres around a mother. " I was looking at you. while the trains of lar thought often move along for some time in simiThey are confused and contradictory. as it is it not well is understood. but there seems to be a complete loss of goal an incoordinate mass of ideas follow each In the flight of ideas we were able to discover some connection. is more In difficult to characterize." The train of thought sup- planted by fixed and familiar phrases. the You always work Harvard Neatness of feet don't win for hardware store. be called an external flight of ideas in might contrast to an internal flight of ideas characterized by internal associations. ideas. and finally to simple sound associations. combinations of common It words. influ- ence of linguistic ideas clearly outweighs that of the . feet. in which the content of thought quotations. visit 31 of the patient's In the following example. that does not want sweet soap. between the separate links of ideas.

very well. since the government has given me permission we will be good friends. the But the chain time it is. in the midst of their inco- herent jumble. David." repetition of single words or phrases which so frequently is occurs in the catatonic productions. Megalomania. Now I will at once see what This example does not show. but only wanders with numerous and bewildering Distractibility digressions in the same general paths. [What is ing at all. [Why are you here ?] how are you empress. noth22-7-1872. following: "You don't own this building. [Do you feel well ?] Oh. this (the : physician's tions are enclosed in brackets) " [Why are you here Because I am I there and everything permission. Carl David the first and Olga. ! Insane. ? Even a member of the reserve. thanks.32 GENERAL SYMPTOMATOLOGY always tends toward changing goals. Oh. must always be close (claps her have nothing (grasps at the watch chain). but the newly aroused ideas do not serve as bases for others. train of thought does not progress at all in In this way is it is often possible. The dear parents were already was already there and had given me have also learned stenography. is nothing. but simply intrude into the desultory train of thought in an incoherent manner. [Will you I will not come again ?] run after him hands). [How I old are you ?] that ?] Nothing. Ah. let me write something. never confirmed . following The ques?] an example of the empress. to obtain coherent replies to questions. I do not know. I When he comes (laughs). and shown in the that. through internal and external influences may also be present to a marked degree. circles . Why. God my brother. however. the any one direction. megalomania. always flight of ideas the course and hence never attained entering on the other hand. therefore. I know The Hartford pigpen never supported. and is. new in this form.

it. syllables. . . — — f ellio. dear . The white immortal eternal receipt. therefore will not be supported by those who have confirmed food. " Ellio. f . Mars war I have the white immortal eternal receipt. while in the severest forms of always some goal idea even though it rapidly changes.DISTURBANCES OF MENTAL ELABORATION food. of concepts. f Catholic Church. sions consist of actual words here there is a perfectly senseless repetition of the same sounds with only insignifi: cant modifications. The war world or the war planet Mars. and the Neither action of the mind itself (imagination). — selo. planet. or war world Mars. Human knowledge has two free sources . memory. f . inference are the most complex products Since perception. White immorThe war planet Mars. White immortal eternal receipt for its existence and confirmation receipt." and so on in monotonous repetif f associations seem to play an important role Sound tion. here. devo. . like the following altomellio-altomellio. therefore are not supported 33 and this building will pay tal eternal receipt for that food. source of their derangement. heloo old f f f and new father. f . . the formation and the association of ideas are their necessary preconditions. dear father." In extreme desultoriness the speech consists of a mere flight of ideas there is series of letters. f . or sounds. and the majority of the expres. experience. Disturbances op Judgment and Reasoning Judgment and of the intellect. The Hartford pigpen for that and food which confirmed is not supported or has not confirmed food or the laws of food. e. — it to new ideas. f . but the train of thought does not advance through . eloo. ellio . e. — . they will be more or less affected by every But this is not the only imperfection of these processes.

34 GENERAL SYMPTOMATOLOGY is source entirely independent is of the other : empirical knowledge tion. Even in most highly cultured persons . Even in children invention and experience are sometimes only partially differentiated. and habit. but even here the natural incompleteness of our apprehension or our habits of If the data furnished is into error. and not only persist in spite of experience. which arises from the recasting and interpretation of Their experience. ideas firmly fixed by tradition. Dog- matic opinions. A feeling dependence and insecurity in the presence of the unknown and mysterious is the fertile soil of superstition of helpless in primitive races. is essential characteristic of these beliefs their emotional significance for the individual. imagination free to the field with its own creations. Empirical science has slowly supplanted survives many of the still misconceptions of primitive thought. education. the force The emotional significance of such beliefs has its basis in their relation to vital interest. we sharply differentiate empirical knowledge from pure belief. while even among the cultured there are beliefs which no experience or arguments can shake. even the wildest imagination employs material which originally came from experience. acquire an overwhelming emotional value. (cf. Whenever invention can be easily tested by direct experience the line between the two becomes more and more to sharply denned. but even mould experience into conformity with themselves of prejudice). mythological interpretations and traditions are as credible them as direct experience. while never free from preconception and expectaNevertheless. thought may lead us by experience is scanty fill or unreliable. but superstition among the uncultured The . Primitive people do not draw this distinction.

They do not from belief. The flight of a bird is an omen of good fortune an accidental gesture reveals sudden danger. therefore. becomes an important factor in morbid conditions the most innocent events are construed as mystic symbols of secret occurrences. but they exercise a marked over patient's emotional attitude toward his environment. Experience. never the the ferent to the patient except in cases of advanced deterioration. are morbidly falsified beliefs which cannot be corrected either by argument or experience. . so in disease the mysterious creations of the imagination are most welfare. These peculiarities of normal thought help us to underDelusions stand the delusions of diseased consciousness. because they do not originate in experience. . Just as in health the self forms the point of reference for our thoughts and feelings. to The tendency so often encountered in health. and simplest facts are full of mystery. although more or dependent on the rational elaboration of experience tion for their content. Further proof of the subjective origin of delusions is found in the close relation which they maintain to the ego of the patient. arise experience or deliberation. they are always due to a morbid interpretation of the events arising in the patient's own imagination. are characteristically inaccessible to opposi- and argument. but from Although often associated with actual and falsified perceptions (hallucinations or illusions). is . consequently. intimately connected with the patient's own indif- The delusions are. Delusions are inaccessible to argument. They are not only referred influence to self. draw sweeping conclusions from insufficient data or to assume a causal relationship between purely accidental occurrences.DISTURBANCES OF MENTAL ELABORATION political 35 less and religious convictions.

Clouding of consciousness is sometimes a factor in the development of delusions. where we are unable to detect or correct those contradictions fectly clear to us fore. which rendered their correction impossible. Moreover. sorrow and fear exert the strongest influence on the falsifications of ideas. clearly indicating a morbid condition of consciousness. give rise to them persist. In morbid conditions. Delirium tremens and fever delirium. fears and hopes which really have nothing to do with the subject matter. the change is not due to argument. We have an example of this in dreams. sorrow.36 GENERAL SYMPTOMATOLOGY unable to correct them as long as they remain deluOnly in convalescence. Vivid emotional states. such as fear. in the consideration of any subject. The delusion needs no other support than the absolute conviction of the deluded. especially in delirious states. joy. prei sent a host of fantastic delusions with but very little emotional disturbance. can they be recognized as false. on awakening. a new one is quickly found. At the height of the disease they are as firmly established as So long as the morbid conditions which reason herself. the delusions are unchanged. delusions which are firmly believed one day may be recognized as false the next. when they become a mere sions. for instance. the external object of reference or support is Even when destroyed. Even in health. If Our argument may drive the patient to admit non-essential points. memory of delusions. anxiety and enthusiasm create for us. which are perWithout doubt. but the delusion serenely reasserts itself. there- we must regard the clouding of consciousness as an . but to a change in the morbid condition. they are relinquished or modified. and enthusiasm are important factors in the origin of delusions. anger. notwith- standing the most evident self-contradiction.

paralytic.DISTURBANCES OF MENTAL ELABORATION essential preliminary condition 37 for the development of delusions. self. and precocious dementia run their course without delusions. But congenital mental weakness shows only a slight tendency to the development of delusions. and to regard as invention that which does not conform to our knowl- . While they have no power over us. on the other hand. firmly in their thoughts feeling. the we is are led the assumption that essential factor an inadequate In health we are functioning of judgment and reason. In paresis. and likewise many cases of senile. and dementia praecox delusions appear in i which neither emotions or disturbances of V -* consciousness play a prominent role. sions cannot. and facts conduct. for the patient. Another source of delusions may perhaps be found in those peculiar ideas which in health are accustomed to occasionally " pop " into our heads. After this preliminary consideration of relative to all the to the origin of delusions. all sorts of which permit delusions delusional fancies to spring up in the patient's mind. even though soon changed for others. therefore. The psychic weak- which is a prominent symptom in these diseases. accustomed to judge all our fancies according to the standard of our own past experience. senile dementia. lie The real cause for the delu- in the psychic weakness of it- but only in the accompanying conditions of excitation. they bear the stamp of absolute certainty. originate It can be easily demonstrated that freely most during heightened or depressed moods. and wbose origin we are unable to account for. seems to favor the development of delusions. They often intrench themselves and dominate experience. ness.

or he disregards it and hides it under assumptions which are even more fanciful. are variegated fantastic pictures recurring in manifold forms. the fact that these ideas become delusions and acquire a -power which even the senses cannot destroy. The doctrine of " monomania. The character and duration of delusions differ according to their mode of origin.38 edge. correct. to oppose. with little or no mental elaboration or coherence. Those which originate in consciousness. was based upon this assumption.and the subsidence of the emotional disturbance. They likewise disappear with the clearing of consciousness. emotional disturbances change with the patient's mood. or suppress his delusions. Delusions depending of both upon emotional disturbances mental deterioration and upon do not vanish with the fading the emotional states. They are gradually forgotten. not only the impulse. The development of delusions is thus seen to be based on the general disturbance of the entire psychic life. The cause of this disability was formerly sought in the peculiar attributes of the individual ideas. They are probably incited by emotional fluctuations which transform slumbering hopes and fears into imaginary ideas. can only be explained by an inadequate functioning ofjudgment. ." which held that the " fixed idea " was only a circumscribed disturbance of an otherwise healthy psychic life. and usually disappear with the emotional disturbance. Delusions of delirium. Clearly the patient has lost. which are determined both by clouding of consciousness and emotional disturbances. clouding of But and toeakness of the reasoning power. dictions GENERAL SYMPTOMATOLOGY The patient either does not perceive the contra- between his fancies and his former experience. but the power. dependent on impassioned emotioned excitement.

as in the paranoid forms of dementia praecox. are always of shorter duration. cox. Persistent delusions are of two types. deemable. Among depressive delusions. as in the paranoid form of dementia praecox. and senile dementia. either as self-depreciation (depressive delusions) or as self-aggrandize- ment (expansive delusions). or they may become permanent through frequent repetitions. without systematization. this idea of guilt In states of morbid depression be associated with the patient's is may . every action. The former may ultimately disappear. and senile psychoses. Practically all delusions centre in the self. delusions. life. as in dementia precox. in paresis. 39 Such delusions occur In these reappear for short dementia praecox. He believes that he constantly injuring and deceiving others his past appears to him as a mass He is an irreof abominable deeds and terrible crimes. sometimes found in paresis and dementia prae. apprehension of self and the environment but even here a decided weakness of judgment is probably always deThe somewhat similar system of coherent monstrable. psychoses the forgotten delusions may periods during emotional exacerbations. In this form the delusions become the basis of a thoroughly elaborated. the unsystematized and the systematized. but falsified.DISTUKBANCES OF MENTAL ELABOEATION but are never corrected by reason. end stages of chronic alcoholism. paresis. unfeeling creature. those of self-accusation stand closest to the normal Many normal patients torment themselves with the belief that they are unlucky. The \ progressive and uniform systematization of the delusions without marked mental deterioration constitutes paranoia in the strict sense of the word. repudiated by God and . Witb continued moderate emotional excitement delusions may be firmly held and even elaborated.

Food and drink have a peculiar taste. or whatever else his ingenuity can invent. Related to these delusions are the general fears of poverty. the stake. the scaffold. also. or some other misfortune about to befall In progressing mental weakness themselves or relatives. loss of work. Men call after him. The patient sees himself involved in a network of secret hostilities and imminent dangers which he cannot escape. In advanced mental weakness the often assume a very fantastic form. whisper to each other. All are joined against him and gloat over his misery. especially auditory. finds in letters arrange- ments for his secret meetings. They originate during periods of indispo- sition. references and even indirect All assertions of friendship are disbelieved. The wife is embarrassed by unexpected return home. The detects fond glances and secret signs. patient notices a coolness in marital relations. Mistrust and suspicion are excited by peculiar coincidences articles marks. persecutory ideas delu- Absurd somatic . coughs in a significant manner. this form of delusions may become is nihilistic. A large group of depressive delusions are those of persecution. the last child does not resemble its father. in front of him. spit etc. At this time. Delusions of jealousy also play a prominent role. non-existent or less than nothing. as if poisoned. there usually appear hallucinations. a form scurries by the window. the room is darkened. and consequently about to suffer a fitting punishment. etc. discomfort. the patient included. shun him. or anxiety. arrest. Outside some one pounds on the door.40 GENERAL SYMPTOMATOLOGY is damned. love and Newspaper and misinterpreted reand popular songs contain insults. when every- thing. tries to conceal something. etc.

common Sexual delusions are especially common. expansive delusions. feeble paretics extol. Thus. or hypnotic influences. All these evils may be attributed to any individual or group of individuals from the neighbor or husband. sexual excess. Expansive ideas may also be referred to a somatic basis. that they will die at once in order to be translated to heaven. they send invitations to their own execution. Sometimes delusions with a depressive content Patients state acquire the significance of expansive ideas. electrical. etc. are similarly transformed by spiritual authorities. although they cannot produce a single musical tone or even stand on their feet. temporal and Noble descent. are forms. social position The external relations of the patients. With the onset of deterioration the delusions become absurd and fantastic. The delusion of mental soundness in spite of deep-seated mental disease. Rhine wine. varying from mysterious sexual excitation to imagined childbirth during stupor. to the Freemasons or Social Democrats. their gym- nastic dexterity. the urine. Closely con- nected with the hypochrondriacal ideas are such expansive ideas as that the excretions are gold. which is to be conducted with great pomp. Harmless physical symptoms are regarded as signs of syphilis. as in paresis and paranoia. many patients not only consider themselves perfectly sane. but remarkably intelligent. In hypochondriacal delusions the object is some incurable disease. the and property. constitutes an absence of insight into the This absence of insight is almost universal in disease. their beautiful voice. close relation to the even association with supernatural powers. magical. morbid states . paresis. etc. . are among the most frequent forms. such as telepathy.DISTURBANCES OF MENTAL ELABORATION sions of transformation 41 and witchery.

including whole continents or the world while vague plans of gigantic undertakings fill their minds. however. and to a moderate degree after the use of tobacco. another very closely. patients boast of their untold wealth and vast itself. to recognize We are. Some unpleasant emotional states produce the same result. Retardation occurs even in healthy individuals as the and mental fatigue. ether. but rather spontaneous sequences of the internal condition of the patient. able two disturbances . His detention the result of jealousy or These relations are not the result of logical elaboration. ceptional They may The victim co-exist or follow one of persecutory delusions discovers an inadequate cause of this persecution in exability. and somehas been times even in the same individual. chloral. natural right to is great possession or high positions. is . that it impossible to establish a standard by which morbid deviations can be accurately estimated. namely. estates. retardation and acceleration of the train of thought. On the other hand.42 GENERAL SYMPTOMATOLOGY further development the patient becomes the Presi- With dent. This disturbance is characteristic of the depressive and mixed forms of manic-depressive insanity. and independent conIn dementia praecox the appearance of expansive ideas following delusions of persecution indicates a decided progress of mental weakness. the Pope. chlororesult of physical form. Depressive and expansive delusions are by no means mutually exclusive. Disturbances op the Rapidity op Thought The normal rapidity of the association of ideas and con- cepts varies so greatly in different individuals. or God. Christ. intrigues. It also occurs during the intoxication produced by alcohol.

Melancholiacs and neurastheniacs recover very slowly from the effects of mental. which we call practice. Disturbances of Capacity foe Mental Work The capacity rapidity of for mental work is independent of the measured by direct experimentation. in part of dis- eased mental tone. and physical activity. and by such drugs as morphine.DISTUEBANCES OF MENTAL ELABORATION 43 found in the end stages of dementia praecox and paresis. particularly in congenital hnbecdity. In nor- mal life it is produced only by some forms of emotional In morbid states genuine acceleration In flight of ideas the thought excitement. although it forms a most important symptom of mental disease. susceptibility to fatigue find it is in very general in most forms of insanity. and paresis. emotional. but even here real delay can usu- ally be demonstrated. in part also it results from disturbances . masked often Recovery from fatigue is effected by relaxation and striking especially by sleep. It is scarcely to be efforts. In normal life the capacity for mental work is determined by the residua of past thought. caffeine and ethereal oil of tea. Acceleration is less frequent than retardation. and in congenital imbecility. may appear accelerated. where it is often the first symptom of the disease. We exhaustion psychoses. The capacity to susceptibility for mental work stands Increased in inverse ratio to fatigue. dementia prsecox. Moderate retardation appears also in melancholia. con- genital imbecility. is probably never found. In morbid states the effects of practice are usually lessened and rapidly disappear. These residua condition the increase of capacity. This is the result. In neurasthenia it is by increased nervous irritability.

have already been delineated in the discussion of delusions. where quite insignificant forms of irritation may become altogether intolerable. DISTURBANCES OF SELF-CONSCIOUSNESS The sum total of all those presentations which form the complex idea of our physical and mental personality constitutes self-consciousness. and shows an incom- abatement of It its profoundness in the morning. or finally distracting influences.44 GENERAL SYMPTOMATOLOGY amount but depth. Falsification of self-consciousness is. therefore. in excited periods of and and probably also dementia praecox and paresis. All morbid experience. The is increased susceptibility to distracting influences lar a regu- symptom of neurasthenia. self-consciousness is determined by the experiences of each individual. especially in manic-depressive insanity. This is the permanent background of our mental life. In content as well as scope. Its most important forms. It of sleep. must eventually disturb the apprehension of the individual personality and its relation to the external world. a very frequent disturbance. from unusual vividness of individual pres- from an increased susceptibility to Inadequacy of the goal ideas is probably the cause of distractibility in paresis and dementia entations. In advanced deterioration self-consciousness ultimately . and exercises a great influence on the course of all our mental processes. therefore. however. Finally the capacity for distractibility . not only in has been shown is that in conditions of simple overwork the sleep attains its greatest depth very slowly. praecox. plete light. work is markedly decreased by can arise from insufficient intensity of the goal ideas. The vividness of individual presentations is seen in the distractibility of acute exhaustion psychoses.

the patient still retains his self-consciousness and can give an account of his ularly own condition. In dementia praecox and paresis life.DISTURBANCES OP MENTAL ELABORATION falls into 45 this is decay. the usual terminus of the mental In some cases. This is partic- common in epileptics. on the other hand. even when the store of ideas is much impoverished. .

This striking disproportion between disturbances of the intellect and the emotions is most pronounced in dementia praecox. istic of This character- most forms of mental deterioration. Therefore. In normal life one's interest in the environment is reflected in more or less intense fluctuations of his emotions. Disturbances of the emotional striking life often form the cult. 46 . emotions show marked personal peculiari- closely allied to the abnormal. Emotional indifference may be marked even when external impressions are well apprehended and elaborated. In paresis. the feelings are a direct indica- tion of the attitude of the ego to the perceptions of the external world. DISTURBANCES OF THE EMOTIONS Every sensory impression which sustains any intimate relation to man's welfare is accentuated in consciousness by a concurrent feeling of pleasure or pain. on the other hand. Diminution and Increase of Emotional Irritability The diminution of the intensity of the emotions is their simplest and most frequent disturbance. first symptom of disease. depending on its apparent tendency to advance or retard the general aims of life. But the is diffi- recognition and estimation of these disturbances because we lack an adequate normal standard.0. Even in health the ties. mental elaboration is disturbed to a much greater degree than the emotions. Diminution of is these emotional accentuations indicate indifference toward the impressions of the external world. of which it is one of the first and most striking symptoms.

The absence of these checks in imbecility gives rise to sudden. Consideration for his environment. Lower or sensuous feelings possess a greater momentary same time more transitory than the which accompany and higher moral determine our thoughts and actions throughout our entire life. The active interest of the patient becomes exclusively selfish." in also many forms of congenital imbecility. has no influence on his conduct. outbursts of passion. and all feeling for the higher claims of propriety. He loses the sense of shame and lacks all comprehension of the conventions of social intercourse. and act as checks on sudden emotional impulses of intensity. He loses all pleasure in mental work. the lower order. also. and sometimes an early symptom prominent in of paresis. Without a . This emotional deterioration ing is very often the occurs first strik- symptom of dementia prsecox. disease. but are at the sesthetic sentiments. especially the so-called " moral ness in the attainment of which the patients show a certain shrewdselfish advantages which often conceals the real severity of the disease. but transitory.DISTURBANCES OF THE EMOTIONS All phases of the emotional 47 life seldom suffer equally. external world. morality. and religion. In its simplest form it appears. relatives. and finally for mankind in general. his family. Naturally the patient loses most easily those feelings which are not directly connected with the changes of his own ego. and further those feelings which have lost their sensory properties and are aroused only through the higher mental processes as concomitants of general ideas and moral principles. in simple senility. is Emotional deterioration imbecility. but are related to the more remote. is and advances with the in senile progress of the It regularly dementia.

and often complain that they are forsaken and desolate. a plunge the patient from the most found despair. In these conditions a definite fundamental emotional tone may prevail in the midst of the various rapid changes. strong outbursts of . Lighter grades of morbid emotional activity are very often observed in some forms of congenital imbecility.48 GENEEAL SYMPTOMATOLOGY life firm foundation for the emotional word. giving rise to rapid emotional changes and sudden transitions from one to another. mood the This change of "emotional tone" of is an im- portant and characteristic symptom. capriciousness. These are characterized by frequent and abrupt alterations of mood. giving way to in its opposing influences. especially in excitement of the maniacal forms insanity manic-depressive and in paretic excitement. Every accidental impression has a lively emotional accentuation. The retardation depressed manic-depressive sometimes presents a superficial similarity to the emotional indifference of the deteriorated. only to recur just as abruptly former intensity. in paresis. the tone of the voice. so the emotional attitude varies constantly in accordance with the ever changing impressions of the moment. is A permanent patients characteristic of emotional indifference lack of insight. Increase of emotional irritability is characterized by fre- quent variations of mood. blissful self-complacency into the This is most proan especially prominent symptom indifference characteristic of is The emotional the end stages of dementia praecox regularly accom- panied by such emotional of ebullitions. in hysteria. As the train of thought leaps unsteadily from one subject to another. and during convalescence from exhaustion psychoses. but the former realize their condition. suffices to a mere trifle.

transition period between depression and excitement in manic-depressive insanity.DISTURBANCES OF THE EMOTIONS feeling 49 upon slight provocation. they grumble and growl in the most intolerable manner and show outbursts of pasThis occurs in the sion upon the slightest provocation. of depression in The patient is unable to enjoy any- All the natural pleasures of existence are trans- formed into a feeling of painful ennui. is A similar phe- found in the nomena in the border-land of insanity normal life when temporary gloom seems to pervade experience. delusions of persecution. Persistent Morbid Emotions tional irritability. distrust." self-accusation. Persistent susceptibility to the unpleasant is often recognized as a congenital personal peculiarity in the constitutional psychopathic states. . and a tendency to undue enthusiasm or gloom. annoyed by every trifle. emotional state naturally induces "painful and The increased susceptibility to the unpleasant is sometimes associated with irritability. Patients are usually fretful. also in convalescence from of the exhaustion psychoses and in melancholia. This increased susceptibility to the unpleasant is a pro- nounced but transient accompaniment various psychoses. irritability of the epileptic The passionate is and hysterical patients same type. The feeling tone most frequently encountered here is sadness. at variance with themselves and their environ- ment. thing. fear. which finds vent in expressions of intense displeasure. The unpleasant thoughts. persistent In contrast to both the diminution and increase of emo morbid emotions are characterized by the persistent domination of some definite feelings over the emotional life. dis- contented.

Lighter grades of fear. In acute mental disturbances the indefinite anxious forebodings become fixed into more or less definite fears. is always accompanied by a clouding of consciousness. in delirium. shut and clinch their teeth. and indeed are often well aware that their fears are groundless. Anxious excitement is characterized by efforts at defence and escape. but may be their eyes. like all extreme emotions. Fear is most pathognomonic of melancholia of involution. being accompanied by precordial oppression. and sometimes by perspiration and an increased tendency to urinate and defecate. where it is seldom absent. Extreme fear. Fear is manifested by anxious excitement and by anxious tension. Anxious tension is not maintained at the same intensity for any considerable length of time. present also in the dreamy states of epilepsy. stitutional psychopathic states the indefinite fear often as- sumes peculiar forms. and assaults. but shows remissions.50 GENEEAL SYMPTOMATOLOGY Fear is most important persistent emotion Even in normal indisympathetically viduals it affects the entire mental and physical condition. The patients feel afraid without knowing why. In morbid conditions fear is usually without an object at first. and the like. are among the most frequent and char- . Retarded patients of manic-depressive insanity try to present to the threatening danger the fewest possible points of attack. increased respiration and tremor. supplication for clemency. as the feeling of homesickness. suicidal attempts. especially at night. Paresis often presents the most extreme form of fear. palpitation. and in the beginning of catatonic excitement. It occurs frequently in depressive forms of manic-depressive insanity. crouch down. paleness. in the form of permanent timidity and cowardice. In the con- by far the encountered in morbid conditions.

The feeling of increased strength.DISTURBANCES OF THE EMOTIONS acteristic states. that in tear- ing up any scrap of paper they might have destroyed valufeelings of discomfort Other closely allied disturbances are the which arises whenever individuals are compelled to others. paresis. knives. and These the desoil for are constantly in fear that they will do wrong. of open or closed doors. etc. . restlessness. enthusi- asm. manic-depressive morphin and cocain intoxication. crowded rooms. glass. as further action of the drug causes irritability. that they by contact with might have swallowed needles or fragments of able papers. congenital peculiarities form a favorable velopment of a further group of disturbances called compulsive fears. especially tability. The morbid feelings of pleasure are less frequent than into come those of displeasure. needles. 51 symptoms of the constitutional psychopathic The patients from youth lack self-confidence. as in erythrophobia. the fear of p. 383). and alcoholic psychoses. . the emotional disturbance This belief is subis believed to have a similar origin. and aimless activity. etc. In paresis stantiated by physiological experimentation. etc. which include the fear at the sight of or contact with certain objects. as spiders. any sort of relations with morbid blushing. the pleasurable feelings are apt to be marked. In the maniacal forms of manic-depressive insanity in which there is a similar combination of pleasurable feelings. irri- and pressure of activity. that they themselves are others. intoxications They occur especially in alcoholic insanity. also the fear of being alone on deserted streets. and enterprise which result from alcohol probably originate in the facilitation of the release of motor impulses in the brain. (see These patients are tormented by the idea that fit their clothes do not soiled or poisoned properly. dementia praecox.

known. arise In dementia praecox. pleasurable feelings take on the form of a silly. as well as in delirium tremens. due purely to a the bromides produce a feeling of well- being by relieving previous states of uncomfortable excitement. which is a personal some normal men. purposeless hilarity and exuberance. and the bromides also produce characteristic feelings of well-being. feeling of ecstasy. in epilepsy. however. morphin. These . which. intellectual. to bear no relation to the patient's ideas and environment. these the feeling of well-being. which occurs especially and sometimes in hysteria. feelings often exist unaccompanied by motor excitement. sometimes primarily emotional and sometimes arise may many different disturbances.52 GENERAL SYMPTOMATOLOGY In this disease. during the excited stages. however. In tobacco smoking is the feeling of agreeable contemplation soporific effect. with outbursts seem of silly laughter." who never and are always cherishing hopes of great things. called the drunkard's humor. The origin of morbid feelings of pleasure is very difficult The to determine. there is apt to appear a characteristic change of emotional Its origin is unattitude. seems to be very similar to the dreamy state which follows opium smoking. in contrast to the hilarity of the maniacal forms of manic-depressive insanity. both because they from a great sometimes somatic and vasomotor. presenting a condition similar to that occurring in hasheesh intoxication. susceptibility from the drunkard's into humiliation and his moral apathy to vice. tobacco. Cocain. who look on find everything "fine. but may. The optimistic characteristic of emotional tone. In chronic alcoholism. becomes really abfickle individuals normal in those serious matters seriously.

on the contrary. They are to be regarded which gradually develop out of the experience of countless generations into involuntary and instinctive impulses.DISTUKBANCES OF THE EMOTIONS are characteristic of 53 some forms of the constitutional psy- chopathic states. we miss at first the painful weariness and hunger which makes the restoration of our strength so easy. while hunger gradually returns as soon as we begin to . In morbid conditions these general feelings may suffer profound disturbance. eat. In ordinary life these feelings inform us of our bodily needs. as admonitions. When at last we have the opportunity to attend to our needs for rest and food. such as feelings of fatigue and hunger. Disturbances of General Feelings. General feelings are those emotional states which stand in close and inviolable relation to self-preservation. Upon remission of the excite- . only thoroughly silenced when the indicated need is relieved in some way or other. In normal life a general feeling may disappear when we pay no heed to it. and they imperiously exact actions adapted to the circumstances. actual need for rest. The performances of these actions can usually be inhibited by conscious volition. Fatigue may fail to indicate the Especially in maniacal forms of manicis depressive insanity there often a complete absence of weariness in spite of the fact that patients are exhausted by continual restlessness. al- though often only by means of great self-denial the feelings themselves are. Only when we have rested for some time do we again experience a feeling of weariness. . We are able to overcome weariness when work demands our strength hunger abates when we are unable for a long time to satisfy it.

They recklessly soil themselves. as the patient is unoccupied and possibly constates of paresis. not only and impel us to keep clean. The feeling of hunger is similarly disturbed in these same psychoses. The lack of weariness occurs in the excited and in catatonia. not only our bodies. and in the constitutional psychopathic states. Such consume the most disgusting things. or animals. These patients also lose those feelings which cause us aversion at the mere contact with filth or dirt stones. In paretic and catatonic patients there is often a senseless voracity. without any perceptible relation to the state of bodily nutrition. in exhaustion psychoses. even their own dejections. although the well-nourished no need of such an amount of nourishment. Severe disturbances of the feeling of nausea are almost of a far-advanced deterioration. the feeling of weariness is constantly present. there of hunger. In the constitutional psychopathic states and in hysteria. but our whole environment. on the other hand. however. Both disturbances exhaustion and exhaustion without weariness associated in an odd cially — weariness — without are often espe- manner in neurasthenia. The patients. the weariness often comes over the patient in full force. although there is no real exhaustion. either permanently or at certain times. but constantly overpowering their nausea from pure greediness. they do not secure upon retir- ing at night. on the other hand.54 GENERAL SYMPTOMATOLOGY ment. pieces of glass. . always signs patients with suicidal intent. Not infrequently they swallow nails. In states of depression. as the weariness preparatory to sleep will not come to them. patients have may is be a prolonged absence of the feeling which suddenly replaced by gluttony. fined to bed. rest feel feeble without sufficient cause. unstrung and incapable of work but.

exclusively in connection with persons of the associations brutality. and also in the excited stages of paresis and the maniacal forms of manic-depressive insanity. their urine.. in An increase of sexual excitability is found some idiots. but in a more pronounced degree in dementia prsecox. The of which pertain to the maintenance the race rather than to self-preservation. even severe injuries produce no sensation at all. especially in paretics. increased. In conditions of excitement. The feelings of -physical pain are often abolished. especially with intense fear. etc. also in morphinism. This insensibility to physical pain is often found is in demented patients. by . Such patients pluck out their tongues or eyes. Sexual indifference occurs in many forms of the constitutional psychopathic states. and particularly in hysteria. the destruction of the nervous conducting paths an essential antecedent. abolished. may be sexual feelings. with their own food. 55 own saliva. or same accompanied sex. deeds which would be utterly impossible for a man with a normal sense of pain.DISTUEBANCES OF THE EMOTIONS even intentionally. although consciousness may be perfectly clear. and even feces. Perverted sexual feelings are those in which sexual feelings occur with certain objects. in whom. or perverted in disease. cut open the abdomen. to be sure.

. and in the narcoses of chloroform. The idea* of a definite aim (some change either in ourselves or our environment) forms the starting-point of a volitional act.D. 66 Ordinary impulses find no . while its performance is determined by the intensity and the duration accompanying feelings. action is determined. This idea is accompanied by feelings which are converted into impulses The direction of any for the attainment of that aim. All DISTURBANCE OF VOLITION AND ACTION disturbances of the psychic life find their final expression in volition and action. disturbance. the conduct of the insane is naturally influenced by all those disturbances which occur in other spheres of their mental life. . although the volitional process itself presents no . (2) its release impeded (3) or the direction can be modiby external or internal influences (4) morbid impulses can forcibly suppress the normal will (5) or natural impulses can assume morbid forms (6) finally. and morphin. by an idea. It is characterized by an absence of energy. Diminution op Volitional Impulses The complete suspension of volitional activity is termed It is produced by extreme fatigue. paralysis of the will. therefore. chloral. profound alcoholic intoxication. . Morbid disturbances of volition manifest themselves in the most varied ways (1) the energy of the volitional of the : impulse can be diminished or increased facilitated or fied .

dementia prEecox. screaming. only movements are involuntary and result of defective development. Similarly. and aimless activity. we find marked unrest which cannot be explained by the patient's delusions. the patients are content to little around. but must be referred to a morbid motor excitation. In the end stages of deterioration the reflex. displaying very animation and it staring vacantly into space. show a pronounced restlessness. sit If left to themselves. except in gratification of the lower. Patients will not remain in bed. will occurs in the oration : less complete paralysis of the end stages of progressive mental deterisenile dementia. In dementia prsecox can often be shown that the patients have not lost the volunfail to tary control of their actions.DISTURBANCE OF VOLITION AND ACTION issue in action. and increases to brawling. A more or This is characterized by a marked diminution of personal selfish. and paresis. and constantly busy themselves In alcoholic intoxias if employed in some occupation. hallucinations. initiative. 140) . alcoholic delirium. gluttony. while 57 of personal well-being even the most powerful incentives and moral claims fail to influence the patient. or emotions. inactive. In chronic cocain intoxication (see p. speaking of an increase of volitional impulse only when there is a marked disproportion between the intensity of In the excitation and the importance of the motives. cation increase of volitional impulses begins with simple loquacity. such as greed. and sexual desire. defective volition appears in congenital imbecility as the Increase of Volitional Impulse The universal indication of the increase of volitional impulse But we are really justified in is motor excitement. and vegetative impulses. but normal incentives influence them. for example.

The name "pressure more applicable of activity. Such patients make grimaces. contort the body. great talkativeness. In the lighter hypo maniacal disturbances this pressure of activity takes the ness. Patients themselves really be to this condition. and utter a succession of senseless noises. Catatonic excitement furnishes a picture essentially different from that of the maniacal pressure of activity. though they might at poseless appear pur- and senseless. disrobe. dance. is characteristic excitement in catatonics often .58 GENERAL SYMPTOMATOLOGY motor excitability which seems form a transition to the morbid pressure of activity which a characteristic 288) and there develops a peculiar to is symptom is of manic-depressive insanity (see p. ticulation. incoherent activity. all impulses lead to more or less first purposeful actions. we have to do with movements which at most have no definite aim. marked excitement the goal ideas become more and more inconstant. These movements are not pure volitional acts. finish. form of general instability and busiand a tendency to animated gescollect all sorts of useless things." which has formerly been used for the maniacal stress of action. as there is no antecedent idea of their purpose. destroy everything they can reach. Such patients begin countless undertakings which they never and. the movements are entirely purposeless. wash in their own urine. on the contrary. and pound incessantly with their hands and feet. In catatonia. Patients scream. would Although the more moderate. run about. and one can hardly detect any purpose at all in their ever changing. tear their clothing. In the maniacal excitement. sing. sometimes found in exhaustion psy- choses and paresis. clap their hands. smear themselves. when In more unrestrained. travel aimlessly about. laugh.

we often see vents the consummation of the act. is is the most impor- tant disturbance in the depressed states of manic-depressive probably due to a similar increase of resistance. In spite of every apparent exertion. not only on its on the resistance which it has to overcome. stand up. The name " stupor" is usually applied to these disturbances. but they are only superficially related to the stupor of catatonia. or dress. As a rule they clearly recognize the enormous pressure lying upon them. All the actions are characteristically slow and weak. as in itself is action is occasionally both rapid and powerful. the patients cannot utter a word. . except when a powerful emotional shock breaks through the resistance. But every impulse is almost immediately followed by the release of an opposing impulse which preThus. In severe cases independent volitional action is almost impossible. and which they are unable to overcome. Thus. but it is immediately interrupted and extinguished by the opposing impulse. Here the impulse is not hindered by internal resistance.DISTURBANCE OF VOLITION AND ACTION often assure us that they do not 59 know why they perforin such absurd antics. but also own only by the most strenuous exertion of the will. Such patients require special exertion of the will for almost every movement. In catatonic stupor the release of movements not rendered difficult. and are unable to eat. the desired movement begin all right. The psychomotor retardation. Disturbances in the Release of the Volitional Impulse The strength and pulse is rapidity with which a volitional imis converted into action dependent. fright and fear may present obstacles to the realization of our intention. which insanity. which can be overcome intensity.

Heightened Susceptibility of the Will of action have two sources (1) external and (2) those relatively constant principles of action which arise from within rather than from without. this as an " embargo. In maniacal. and the action goes on without the slightest difficulty. and in conflict with overwhelming morbid impulses. In diseases this control is lost in weakness of the will. In contrast which there is a continuous hindrance. and render the individual's conduct more or less independent of his surroundings. in some retarded states in manic-depressive insanity. where the fixed principles of action are lacking. on the other hand. and some paretic patients." As soon as the might refer to one embargo is raised. There is no internal unity or consistency in conduct. Weakness of will is found in all forms of imbecility. stimuli . there can develop an increase of psychomotor irritability without any signs of to the retardation. On the other hand. catatonic. there is an added motor excitement. In alcoholic intoxication. The control of actions by these general principles is lacking only in children and unstable individuals. The facilitated release of volitional impulses is a general In hyscharacteristic of childhood and the female sex. The most diverse impulses give rise to action. increased psychomotor excitability.60 GENERAL SYMPTOMATOLOGY is but simply quenched by a counter impulse. increased excitability. in actual excitement. not so much on account of their intensity. as because of the lack of the normal restraining influences. besides the facilitated release of impulses there is an increase in the intensity of the movements. teria it takes the form of permanent. the counter order disappears. which is independent of external stimuli. The chief char: The motives .

as the result of extreme muscular exhaustion. carried out only to Sudden resolutions are half The patients are yield to new ones. although involuntarily repeats every word he the same time giving evidence of considerable elaboration of impressions by his ability to solve simple problems. especially cerea flexibilitas. maniacal forms of manic-depressive insanity.DISTURBANCE OF VOLITION AND ACTION acteristic is a hypersuggestibility. such as hysteria." in which it is possible to mould the limbs into any desired position. symptoms is and alcoholism but the whole group of most pronounced in dementia praecox. Indications of these symptoms. but is from it by a It is reaction to internal as well as to external stimuli. cially the catatonic form. condition found in its purest form in paresis. phenomena are induced through suspension of these fixed principles of action by means of hypnotism. effectually prevents all permanent voli- tional control action. 61 through which the paThis Similar tients become the prey is to every accidental influence. In echolalia the patient hears. . epilepsy. In this condition there is often found a moderate. muscular resistance called " cerea flexibilitas. espe. Distractibility of the will is a morbidly easy translation of ideas into action. or who will laboriously imitate everything in their presence (echopraxia). but constant. to conduct what the and of distractibility of the attention is to intellection. once done at started. Transient hypersuggestibility is found in catalepsy. paresis. Less often patients are found who will repeat for some time any simple movement. they tremblingly obey the laws of gravity. are occasionally observed in the most varied diseases. where often the limbs of the patient will remain in any position in which they are placed until. It usually accompanies heightened differentiated sus- ceptibility of the will.

or con- vulsively grasp a piece of bread or torn-off button. The expression of the countenance is also rigid. and (2) by numerous repetitions of the same movements. is In stereotypy also there a morbid persistence of a It is voli- tional impulse once started. the forehead drawn up as if in surprise. but only in certain specific directions. The eyeballs are often turned sidewise and the lips are protruded until they look like a snout. Others grip a piece of bedspread with their teeth. Another the crossing of impulses. . Distractibility of the will is found in cerIt tain conditions of maniacal and delirious excitement. This especially characteristic of the catatonic form of demenis tia praecox. whether good or bad. in which they are begun. so rigid that they can be lifted like a log. kneel in a definite place. probably an example very onset deflected into is disturbance which the impulse at the an opposite direction. These patients remain in the same place and attitude for an almost incredible length of time in spite of the (1) greatest discomfort.62 GENERAL SYMPTOMATOLOGY wholly under the influence of the environment. For instance. They stand in the same corner. the catatonic may push persistently against a locked door toward which he had started. and the eyes often wide open. described above. mask-like. accompanies hysteria and some forms of imbecility as a permanent personal characteristic. the eyebrows elevated. The embargo is of the will. when he could easily leave the room through an open door by a in little completed very differently from the way detour. manifested by (1) con- tinued tension of definite groups of muscles. The is distractibility of the will may not be equal in all directions. where acts are of this. lie in bed with legs curled up and head extended.

to do requested which that they are the opposite from press their teeth together when asked to show their tongue. in stereotypy the senseless repetition another. consisting of ordinary movements peculiarly modified. Stereotyped movements have an unlimited patients The turn somersaults. where only a transient symptom. although . and shake hands with stiffly extended fingers. and numerous repetitions of the same words are among the most frequent forms. rap rhythmically. Grunts.: DISTURBANCE OF VOLITION AND ACTION (2) 63 variety. Diminished Susceptibility of the Will Increased susceptibility of the will in one direction is sometimes accompanied by a diminished susceptibility in Thus. lisping. jump up and down. Mannerisms are a kind of stereotyped movement. Negativism consists in the reaction to stimuli which Patieuts do just are the reverse of the normal reaction. The patients walk with a peculiar gait. close the eyes when an attempt is made to examine their pupils. pick at the clothing or hair. go in straight lines or in circles. naturally prevents a normal reaction to the environment. for weeks or even months. Mannerisms are especially common in speech. hop. In all these movements the teeth. typy is a characteristic of the catatonic forms of demenbut also occurs in exhaustion psychoses and it is tia prascox. and grit These movements can be repeated innumerable times. walk about in peculiar places. and refuse to answer questions (mutism). the patients are absolutely reckless of themselves and their environment. eat in a definite rhythm. Stereo- phrases and inflection. peculiar words. This condition is also the basis for negativism. roll and creep on the ground. drag one foot. hold the spoons at the very end. a frequent accompaniment of stereotypy. in paresis.

especially are taken to the closet. paresis. but in contrast to negativism it always starts with an idea. irritable. and emotional changes. and is more or less influenced by persuasion. and no persuasion can overcome it. but merely resists. is and unruly. and offer strenuous resistance to compulsory feeding. Negativism tients is not due to voluntary opposition. in catatonia. The feces are often reif tained with the greatest exertion. the patients As soon as they are returned to bed. senile dementia. new ideas. and is often dominated by confused. and loss of will probably all have the same basis. . resistance to every : will not allow any one to dress or undress them. It is not influenced by pain. Pa- sometimes admit after the attack that they do not acted as they did. They often occur in the same patient. in stubbornness the general emotional attitude fretful. made absurdly inappropriate. and almost never attacks. and senile dementia is closely to negativism.64 GENERAL SYMPTOMATOLOGY They offer the they sometimes speak spontaneously. the evacuation immediately takes place. but almost always passive. whereas the negativistic patient shows great equanimity. The patient shows fight. allied epilepsy. and idiocy. will not bathe or take care of themselves. malevolent delusions. More- over. he seldom defends himself. and may be easily know why they They are most frequent and are sometimes found in a less pronounced form in paresis. hysteria. stereotypy. Catatonic negativism must not be confused with the conscious resistance of terrified patients. The stubbornness of imbecility. external encroachment most powerful. but when unmolested eat greedily. and the manner of resistance is always constrained and often to pass into one another. Negativism. In catatonia there is no conscious reason for resistance.

and are all a part of the symptoms of the constitutional psychopathic states. and stand in close relation to comthe act The accomplishment pulsory ideas and fears already described (see p. self-inflicted injury. 343). the excesses of wanderings and assaults of the epileptic the morbid impulses of hysteria. Here belong also the (see pp. Impulsive Acts Impulsive acts are distinguished from compulsory in that they do not seem to the patient to acts. which gives no chance for reflection or resistance. well as as the dipsomaniac. theft. accompanied by chagrin and remorse. 51). As a . and fraud. but are the direct expression of a sudden overwhelming impulse. but in marked motor excitement. These disturbances all originate on a basis of congenital morbid endowment. 342. hut seem to the patient to be forced upon him by a will which is not his own. be influenced from without. often caution those about to and adopt measures of them prevent harm is at to accompanied by a feeling of relief. Their origin does not lie in definite feelings of pleasure or dislike. Probably the pressure of activity in maniacal forms of manic-depressive insanity is of this type. and is usually followed by clear insight into the nature of the act.DISTURBANCE OF VOLITION AND ACTION Compulsive Acts 65 Compulsive acts are those which do not arise from normal antecedent consciousness of motive and desire. . the patients struggle against the morbid impulses their approach. They are found in the most varied morbid conditions. others. rule. Compulsory acts are generally accompanied by great emotional excitement.

and sentimental manners. by shameless exposures. In pa- ralysis and inhibition . Less frequently in maniacal excitement there is found an increased desire for food. On the other hand. although restlessness usually hinders the patients from taking : . which in recent . however. stones. shamefaced. by hand pressing. excessive is not infrequently found in idiots. Morbid Impulses A all disturbance of the natural impulses is a symptom of general morbid changes of volitional action. is In these last cases there not a simple increase of healthy impulses. or incessant washing with water. combing and unloosing the hair in lighter forms. especially sexual desires. letter writing. are the morbid sexual impulses. of The same is true the well-known excessive desire for eating suddenly manifested by pregnant women. etc. of psychic processes all the appetites are diminished in excitement. but manifest themselves in ambiguous phrases.66 GENERAL SYMPTOMATOLOGY patient's The consciousness is dominated by one blind impulse without clear motive or realization of the outcome. sea- greediness weed. extreme uncleanliness. by an alternation between seductive. on the other hand. sand. and by more or less reckless masturbation in women. by adornment and flirtation. significant glances. sufficient nourishment. The latter seldom lead to actual assault. feces. or urine. saliva. and the like. paretics. Much more numerous. The execution is rapid and reckless.. and the patients are correspondingly dangerous. and especially in catatonics. are sometimes devoured by such patients. abusive language. but probably a simultaneous perversion of the appetite both in nature and direction. appe- tites are increased. Incredible quantities of the most unpalatable and disgusting things.

on the other hand. Both these usually arise on the basis of an epileptic or hysterical endowment. handkerchiefs.DISTUKBANCE OF VOLITION AND ACTION years have been most thoroughly investigated. while the performance of the act is accompanied by a feeling of relief. The satisfaction of sadism appears to arise from the feeling of absolute power over the victim. all manner of worth- and useless things pyromania. Besides the perversion of normal impulses as seen in the above. the endurance of pain increases sexual excitation or may be substituted for it. the irresistible impulse to steal . In the final stage of its ence. in which the sexual feelings and desires are exclusively directed toward members of the patient's own sex. The impulse appears as an obtrusive compulsion which is resisted as long as possible. ing or parts of the body become either the necessary adjuncts for satisfactory coitus. while that of masochism arises from the most complete subjection to the In fetichism particular articles of cloth- will of another. Sadism consists in the attempt to increase or induce sexual excitement by brutality. shoes. the impulse to burn. pyromania should be regarded as compulsive acts. there is a group of morbid impulses which life. The whole series of abnormal impulses are partial symptoms of a general morbid endowment. and indicate conIt is possible that kleptomania and genital degeneracy. . 67 The most pronounced of these are the contrary sexual instincts. development actual sexual congress is a matter of indifferIn masochism. and finally velvet and furs. or the simple observation or contact with the fetich may satisfy the sexual impulse. seem less to bear no relation to normal Such are klepto- mania. underclothing. The most common fetiches are boots.

carrying with him the documents which prove all and whisper their answers with great exertion. The paranoiac endures his hospital confinement with dignity. there is incessant babbling. senseless grinning or laughter. The moves rapidly about. bite their nails with troubled expression. may from found in excited paretics with more In both diseases speech be reduced to an incomprehensible gibberish. though This is also different causes. sings. on the contrary. by listlessness. Paretics may often be recognized silly ex- by their awkward friendliness and production of sit pansive ideas. . notwithstanding accurate apprehension. they sion lie motionless in bed with fixed expres- manic-depressive. are slow and laborious. his pretensions. or less disturbance of articulation. Depressed patients around collapsed and flaccid. cries. Dementia praecox is indicated by lack of interest. restless. strained attitudes. Delusions are usually betrayed by the content of the communications. In this place we confine our- few characteristic indications. and busies himself with all sorts of things. In extreme retardation.68 GENERAL SYMPTOMATOLOGY Disturbances of Expression The movements by which feelings. talks. The hysterical patients arrange their clothing and hair to make an impression. with sudden impetuous movements. symptoms selves to a of the various disease types occurs in the clini- cal portion of this work. Alterations of speech and writing are of the greatest diagnostic value. and impulses are among the most important clews A full delineation of the to morbid psychic impulses. patients express their ideas. Their movements The apprehensive patients are and wring their bands. with a tendency to puns In maniacal patients and rhymes. plays tricks on his fellows.

small. endlessly repeated (written verbigeration). or even to outbursts of rage and mur- derous attacks against supposed enemies. tion. Cata tonics are often mute for weeks at a time. misuntidy corrections. self-mutilation. no isolated act can be taken as an infallible index of the exact morbid condiDelusions of sinfulness impel patients to penance. showy. is Hysterical patients use innumerable In melancholiacs the individual characters are incomplete. is the expression of the entire psychic we readily understand why it is more or less seriously disturbed by morbid changes in any part of the psychic individual. to restless wandering. placement of words and syllables. and then suddenly begin to speak fluently or sing. is manifested by consame words. The paretic's writing which are often illegible even shows omission. Mel- ancholiacs express their thoughts laconically. stant repetition of the less syllables. while.DISTURBANCE OF VOLITION AND ACTION In retarded patients speech is 69 low and difficult. phrases. The same Catatonic patients cover the paper with unintelligible scrawls. Delusions of persecution lead to mysterious precautions. Disturbances of writing correspond both in content and form with those of speech. or suicide. Conduct arising from a Morbid Basis Since conduct life. marks for emphasis. Hypochrondria- . true in retardation. and hastily written characters. The manic-depressive patient fills sheet after sheet of paper with large. and crowded. or even sensewhile they frequently make up entirely new Their stereotypy words. and often keep up a monotonous lamentation. to misanthropic isolation. although is more or less confusion of speech always present. to the writer. blots. on the other hand. and uncertainty.

and publish pamphlets. to embezzlement or to fraud. brawls. a reckless and striking manner. etc. at the supposed secret lover. The religious paranoiac founds a church and seeks a martyr's crown. and spend large sums of money. At first they act as if intoxicated. are directed public scandals. to breaches of the public order. They irritable. in which they indulge without regard to decency or morality. conflicts with the environment. or injurious and absurd curative attempts. priate The idea that everything in their neighborhood belongs to them induces the patients to innocently appro- whatever they happen on. When associated with expansive ideas. adventurous journeys. attack prominent persons. pre- the patients purchase large amounts of useless pare for mythical undertakings. Paranoiacs systematically prepare their claims. destruction of property. and public scandals.. and quite Patients behave in are ungovernable. and later become still more restless and even dangerous. address letters to prominent officials. and create Love-letters. . stuff. and violent under contradiction and restraint. Mental excitement very soon leads to often to resistance to civic authority. proposals. often with the evident purpose of attracting attention and sympathy. In their attempts to compel notice they appear on the street in unusual costumes.70 cal delusions GENEKAL SYMPTOMATOLOGY may lead to revolting smearing. self -mutilation. are regularly accompanied Such excited states by all sorts of mad pranks. There is usually also a tendency to sexual excesses.

FOEMS OF MENTAL DISEASE .

.

influenza insanity. infection delirium. typhoid delirium. Other writers describe these under the various diseases which they accompany. are fever delirium. the onset of infec- The remaining diseases. as. developing during or following the fever. and insanities following exanthemata.FOEMS OF MENTAL DISEASE I. Fever delirium follows rather closely the clinical course and in a measure depends upon it. group includes the various forms of mental disturbance which follow the infectious disease. features are the different diseases. INFECTION PSYCHOSES disturbances here described are supposed The mental They to develop primarily from toxins of infectious diseases. The mental symptoms arising from the toxins of the different infectious diseases cannot as yet be sufficiently differentiated to permit of their being considered as characteristic of the correspond- The only distinguishing physical symptoms characteristic of the ing disease. pneumonic delirium. of the fever. and psy- choses characteristic of the post-febrile period. It is still a question whether the changes in the cortical neurones are due directly to the toxins produced by the 73 . independently of fever. The corresponds to the at. appearing tious or near. and are apt to lead to permanent mental enfeeblement. infection delirium initial deliria of other authors.

women. In addition there should be included alcohol. Fever Delirium The clinical picture of fever delirium presents different grades corresponding to the intensity of the toxic action varying from moderate irritaand finally to complete destruction. and a desire to be left alone. some restlessness. and nervous men show a tendency to develop delirium with any severe form of fever. In the lightest grade of fever delirSymptomatology. and disturbance of circulation should be regarded as causative factors. These dreamy experiences are interrupted momentarily by a return to patients through . which apparently is modified only by the rapidity of the development of the upon the cortical neurones. a feeling of numbness in the head. general hyperaesthesia. influence on the type of delirium.74 FORMS OF MENTAL DISEASE micro-organism. tion to paralysis — fever. the bedpost assumes the form of an illusions angel. the rise in temperature. which plays such an important part in pneumonia. its intensity. and duration. insomnia with anxious dreams. The designs on the carpet and ceiling appear as moving forms or grinning faces. have airy floating sensations. and the individual powers of resistance. Besides the toxin pro- duced in the eration of febrile disease. is a marked clouding of con- and hallucinations largely dominate ideation. or to an autotoxin developing within the body as a result of the infectious disease. rendering the association of ideas dreamy. The form of febrile disease has very little Etiology. A. and are led about gorgeously decorated rooms. accel- metabolism. as it is well known that children. Frightful outcries or beautiful music are heard. — In the next grade there sciousness . ium there is irritability.

Some of the delusional ideas held during the disease for a long time. The emotional The becomes activity increases greatly. he is oblivious to roundings and unable to indicate his desires. The urine and feces are passed involuntarily. or may end in . believed that his brother had misconducted The prognosis is naturally poor because of the severity If of the initial disease. consist in The utterances become indistinct. either 75 attitude much exalted or depressed. indicating the onset of paralysis. which soon become irregular and uncertain. At this time carphologia appears with sub- sultus tendinum.INFECTION PSYCHOSES normal consciousness. In the fourth grade the movements become absolutely purposeless. and mumbling over incoherent words and sentences. Course. There are many varied emotional outbreaks and frequent wild impulsive movements. which idea he held for several months after complete convalescence. ideation is completely incoherent and irrelevant. the delirium usually subsiding with the temperature. the delirium advances to the third or fourth degree. doubtful. — The duration One of the psychosis in three-fourths of the cases does not extend beyond one week. A few cases emerge from the fever delirium into an exhaustion psychosis. may be retained patient during the delirium attend- ing pneumonia the business and appropriated funds for his private use. From this the patient may enter into a state of coma vigil. Where there is hyperpyrexia the prognosis is extremely dementia. The great restlessness is interrupted by short periods of sleep. in spite of all his sur- when. at least one-third of the cases die. open eyes. In the third grade the disturbance of consciousness becomes very pronounced.

smallpox and malaria. 89). In case of cardiac weakness one must be cautious in the use of the bath. and injury of the patient by escaping out of doors or jumping out of windows. both to prevent to others harm Where general there is very great excitement. — Nissl has reported one case in which there was distention of the vessels of the cortex. it If impulsive movements to is are a prominent feature. with increase of white blood corpuscles and pronounced . less. may be necessary to to improvise padded beds with high sides. typhoid. and stimulant. Besides the treatment of the initial disease. Cold baths or cold packs with friction are most serviceable. the ice cap should be applied to relieve cerebral hyperemia. dementia prsecox. together with the bed treatment and pro- longed baths (see p. accomplished in the insane hospitals through the assistance of a restful and clever nurse. as manic-depressive insanity. or resort padded The use of hypnotics and narcotics distinctly contraindicated. able. rooms. is One of the most important indications constant attendance. Infection Delirium group of psychoses are classified mental disturbances believed to arise from the specific toxins of hydrophobia. if necessary administer a cardiac is For this purpose strong coffee very valu- Antipyretics in this condition are not only use- but often aid in producing the delirium. to make use The same result of is it is usual in sheets or hospitals restraint canvas jackets. or dementia paralytica.76 FORMS OF MENTAL DISEASE Finally. because they appear independently of temperature. the delirium may be the starting-point of other psychoses. this In Pathological Anatomy.

77 The cell bodies were swollen. . Symptomatology. teristic the quartan. ance of is intermittent. LII. between 1 Aschaffenburg. silly. Sometimes they relate frightful and adventurous experiences. which are similar to those produced by experimental intoxication.INFECTION PSYCHOSES degenerative changes in the nerve cells. they see fire and threatening forms. according to Aschaffenburg. Zeitschr. distant relatives are heard talking to them. during the formation of pustules. In smallpox. The patients believe themselves poisoned and persecuted in various ways. In emotional attitude they are sad and anxious. and the processes diffusely stained for some distance. In the initial delirium of typhoid. and seldom with the tertian or quotidian Since the general use of quinine. often entirely replacing the rise and sometimes the other characIt occurs most frequently with symptoms. appearing at the onset of smallpox and replacing In malaria the mental disturbthe fever in malaria. Allg. which may develop directly from the first. f. marked anxiety. the chromophiles were dissolved. there — are. The is quiet and accompanied by pronounced and hallucinations. Karyokinesis was observed in nuclei of the glia cells. temperature. tend to prove that we have to do with a psychosis depending upon intoxication. are damned and cursed. which develops at the beginning of the disease. Psy. hallucinations. condition is rarely encountered. is This second form characteristic also of mental disturb- ance. These changes. 1 two distinct forms. bears the signs of intense excitement. and impulsive movements. incoherent delusions. this mental forms. There delirium of one delusions develop very rapidly delirious confusion with flight of ideas. The other form of delirium.

The treatment in a great measure can be only sympto- matic. they Clear hallucinations of sight and hearing suddenly appear. In typhoid the condition temperature. hemiparesis. and disturbances of speech. Sometimes there of typhoid. indictments for theft or arson and are sought by the police. The prognosis in malaria is favorable. fall of may pass over into a characteristic fever delirium. Besides the psychical the disturbances in these infection psychoses. The prognosis varies. In the delirium often a remission during the day in which the patients remain somewhat stupid and disoriented.78 FORMS OF MENTAL DISEASE is the eruption and pus fever. it a characteristic mental seems. signs of initial the convulsive movements of hydrophobia. . the appear epileptiform convulsions. The clear course is varied. curses. which. is The duration rarely longer than a week. the weakness and headache prodromal eruption of smallpox. results Some believe that they have secured beneficial of the from a thorough flushing with salt infusion. blossoms flying about music. In hydrophobia the delirium ends in a fatal collapse. In hydrophobia there initial may there be is intermissions. or it may fifty clear up with a marked recover. Only forty to per cent. there disturbance. and the enlargement of the spleen in malaria. are only annoyed by the sensory disturbances. must be due to intoxication. hear They see persons walking around the room. body combined In malaria the mental disturbance responds immediately to quinine. while the patients remain perfectly conscious . in fact. in the air. there are present characteristic the various physical diseases .

the patients their former energy. when for a few moments they hear unintelligible sounds. There may be transient hallucinations. hypochondriacal ideas. diphtheria. see faint visions. Not all example. and are very susceptible to fatigue. especially They may at times exhibit a distrust tory fear of poisoning. Symptomatology. they do not appear until after the disappearance of the fever. of manic-depressive insanity — form of psychosis is represented by those and physical weakness which appear during convalescence from severe attacks of infectious dislightest The cases of mental eases. The mental disturbances show in common a more prolonged course and a tendency to mental deterioration. subsidence of the fever. After the subsidence of the fever. idly lie abed. however.INFECTION PSYCHOSES 79 Psychoses Characteristic op the Post-febrile Period of Infectious Diseases The onset of these conditions usually occurs before the In some cases. There is no disturbance of consciousness or apprehension. paralysis following psychoses following the infectious disfor eases belong to this group. In emotional attitude they irritable. and do not exert themselves to even concentrate their attention upon what is being read or spoken to them. the latter associated with aggres- . and find it difficult to and write. sometimes at night. and heavy. and even of their surroundings. They are indifferent. transi- delusions of persecution. or experience peculiar bodily sensations. oc- are rather sad and melancholic. casionally anxious. fail to show They are dull constrained. as dementia prsecox or attacks may appear at this time. as. bearing the same relation to the infectious disease as do neuritic sequelae . They read cannot collect their thoughts.

that the bed moves. and anxious restlessness. sleep suicide. grumbling. and are restless. they are lying morgue with corpses about them. . the hallucinations and delusions disappear. As the appetite and sleep improve. and even yield to emotional outbreaks and suicidal attempts. In manner and ac- tions they are obstinate. They lose weight rapidly. see grinning faces looking in at the window. delusions. the food is not genuine. The confusion continues even after the temperature has subsided and the symptoms of the initial disease have disappeared. faces peer in at the open window. anxious. refusing nourishment. This condition most frequently follows pneumonia and rheumatism. resistive. They still hear threatening voices. Gradually the patients become clearer and more composed. silent. no one is will- ing to do the right thing for them. In actions they are inclined to be reserved. and sometimes diphtheria. do not recognize their friends. They gain insight into their condition.80 sive attacks FORMS OF MENTAL DISEASE and attempts at Physically. some one is after them. but the hallucinations and delusions persist. The patients become completely disoriented. A certain unusual sussleep poorly. they are dismembered and about to die. begin to busy themselves. and resume their accustomed manner and conduct. they are poisoned. and must get out of the bed and at them. Their speech is confused and incoherent. Some one pulls the bedding. claim that God or the Virgin Mary appears in a to them. the course of the fever The duration In the second group the following symptoms appear in : marked clouding of consciousness. and reticent about their and appetite are much dis- turbed. varies from weeks to months. numerous delusions and hallucinations.

They lie or childishly restless and sometimes whining. smallpox. they fail in nutrition. mentia pr&cox by the great disturbance of apprehension and orientation at the onset of the disease. A fatal termination is rare. together with weakness of memory. infectious of the the history to be distinguished by disease. which soon passes In spite of improvement in the into a stuporous state. capable of sions. articular rheumatism. . which is the most severe. and occasionally give evidence of severe cerebral disorder. quiet. and the great irritability in contrast to the anxiety It is to be differentiated from deof the melancholiac.INFECTION PSYCHOSES ceptibility to fatigue. the patients continue dull. begins with a condition of pronounced delirium. This form follows especially typhoid. is . The duration varies from several months to a year. persist for some time. physical condition. the predominance of delusions of persecution over self-accusations. in bed unable to take their food or care for themselves. In adults there may be some difficulty in differentiating It is this condition from melancholia of involution. and always due to some complication. especially hemiplegia. The prognosis only one-half of more unfavorable than in other forms the cases recover after an extended course. and by the absence of mannerisms. A few cases never completely recover. perceiving and elaborating external impres- In emotional attitude they are indifferent. the greater prominence of hallucinations. and in- The third group. Physically. and have to be petted and handled like small children. disturbance of speech. from the depressive forms of manic-depressive insanity by the absence of psychomotor retardation. and epileptiform attacks. and cholera. 81 and absence of the wonted mental and physical energy.

The onset of the disease is sudden. or received a letter. is In de- memory the time element especially .82 FORMS OF MENTAL DISEASE patients The present as residuals. Patients are confused. The pathological anatomy thus far has revealed a certain amount of atrophy in the cortex. apprehension. — Hallucinations of sight also appear. due mostly to a marked shrinkage in the tangential ticipate fibres. have taken a walk. and consequently are constantly enumerating over and over again the very same facts. They forget having just related an incident. Incidents of early and even events which have happened but a few moments before. especially at night. a weakness in will- power. They do not remember having just received a visitor or that they have had dinner. Symptomatology. and expressing similar desires several times during the this defect of same visit. restless. sometimes with a condition of delirious excitement. are not remembered. in which the cells par- very little. Finally. stupor of the the catatonic state by the absence of nega- tivism and stupor of the manic-depressive by the absence of retardation. The treatment bed. is but the prominent symptom the striking inability to of the their remember passing clear events. with pronounced fabrications. a lack of judgment. disoriented. forms consists of rest in cleanliness. which is characterized by marked disturbance of attention and defective memory. in spite retention of life. under this head. a most nutritious and careful watching. and anxious. of all these diet. we have the ^>sycliosis accompanying polyneuritis (Korssakow's disease). asking the same questions. and they are forgetful and The condition is distinguished from the indifferent.

typhoid. and speak of children which really do not exist. besides the characterrelate all with frankness istic polyneuritic disturbances. a week ago. In other cases after still the consciousness becomes clear there remains a pro- nounced defect If alcohol of cations. Physically. If these inconsistencies are pointed out to them. or a year ago. They relate the same incidents with different details. with perhaps continued fabriand a great susceptibility to fatigue.INFECTION PSYCHOSES fective. loss of appetite. differentiation depends upon the history of the exciting causes. . These gaps of memory are filled in with numerous fabrications. and in a few cases progresses to recovery in five to nine months. and defective nutrition. but later become quarrelsome. irritable. in which there may exist a similarly defective memory with fabrications and neuritic disturbances. irritability. has been the exciting cause. the more rapid onset. the prognosis is This form in rare instances has occurred without the accompanying polyneuritic symptoms. The patients journeys and and in all detail visits which they have recently made. and speak of conversations with relatives long dead. The course is protracted. 83 They cannot tell whether an event occurred yesterday. In emotional attitude they are anxious at first. Improvement appears very gradually. they are apt to become much irritated. In a few cases death ensues from paralysis of the heart or through coma. and the absence of speech and pupillary disturbances. memory. less favorable. as the result of intoxication in tuberculosis. — Korssakow's The disease is apt to be con- founded with dementia paralytica. Sometimes they are childish and easily provoked to whining. and infec- tions of the alimentary canal. Diagnosis. or indifferent. there is insomnia.

f. klin. Ueber Intoxications Psychoses. 53. Moln£r. Rundschau. Am. Einfluss acuter Krankheiten. Adler. Wien. Archiv f. Kiel. Psy.. Charite Annalen. it Senile confusion presents a similar picture. but in different. Mueller. 26. heiten auftretenden Geistesstoerungen. silliness is the mode of onset is and egotism are more striking. 659. S. 1881. Archiv f. Ueber Psychosen nach acuten Infectionskrankheiten Diss. Ueber psychiache Erkrankungen bei acuten fieberhaften Krankheiten. Jour. Diss. Province Med. Contribution a l'etude du delire des affections febrile. F. Bd. Post-febrile Insanity.84 FORMS OF MENTAL DISEASE is Furthermore. 475.. A. 19. Psy. Zeitschr.. BIBLIOGRAPHY Kraepelin. Strassburger Inaug. 21. u. The treatment similar to that indicated in the other forms. T. Nr. Hurd. 669. . Psy. besides attention to the neuritis. Allg. Ueber die in Zusammenhange mit acuten InfectionskrankAllg. Psy. Bd. Muenchen. C. 22 Mai. 1892-93. Westphal. 740. XLIX. Bd. etc. Psychosis Polyneuritica. Karl. of Insanity. f. in dementia paralytica the judgment to be as apt much while affected as the memory. Lesser. Ueber die in Zusammenhange mit acuten Infectionkrankheiten auftretenden Geistesstoerungen.. S. 1898. S. 1897. Korssakow.. Bd. Nervenkr. p.. 1882. Roux. S. Bd. 46. 13. Zeitschr.

and chronic nervous exhaustion. wss of blood. t ^great incoherence of thought. following most frequently childbirth. gives rise to two groups of psychoses collapse delirium and amentia. and is characterized by various physical signs and moderate psychical disturbance. others are loss of blood. great incoherence thought. Etiology. and with . excessive mental strain. and a fairly rise favorable prognosis. — Among the exhausting conditions giving is to collapse delirium^childbirth the most prominent . Chronic nervous exhaustion (acquired neurasthenia) follows prolonged and excessive mental strain. The acute diseases which may lead to this condition are pneumonia. and are characterized by marked psychomotor disturbances. which differ only in the intensity and duration of the symptoms.II. Collapse delirium and amentia. hallucinations and delusions. and acute diseases. dreamy illusions. develop as a result of profoundly exhausting conditions. EXHAUSTION PSYCHOSES Nervous exhaustion. which is due to excessive abuse and inadequate restoration of nervous elements. and deprivation with worry. ery85 . complete of tation. with profound involvement of^apprehension. develops more "gradually. influenza. Collapse Delirium This psychosis is characterized by an 'acute onset with disorien- profound clouding of consciousness. a rapid course. mental shock.

changing. alliterations. and scarlet fever. is Cars rush by. They develop numerous* delusions which are'Varied. talkative. in heaven or beneath the earth. cell body. 1897. their own name called out. dreamyT hallucinations and delusions. u. ^Defective heredity half of the cases. Christ has appeared to them. have been robbed and are now to be poisoned.86 sipelas. with staining of the achromatic substance. incoherent. suedwest Neurolog. The orientation is quickly lost everything about the patients change. they hear beautiful music. and . neighbors are passing to and fro. and without much involvement Symptomatology. and both exalted and depressed. gas light appears like the sun. found throughout the Pathological cerebral cortex a fine granular disintegration of the chro- — matic substance of the nerve of the nucleus. Irrenraetze zu Baden- Baden. Alzheimer. have been examined pathologically. there develops very rapidly a condition of ) motor excitement with clouding of consciousness. but are among enemies and thieves. — Following a few days of insomnia and restlessness. FORMS OF MENTAL DISEASE measles. sometimes with a flight of ideas. is Oftentimes a'fright occurring while the patient in a weak condition acts as the exciting cause. announc- many 1 Wanderversammlung d. and repetitions. Numerous illusions and hallucinations appear the designs on the carpet assume the form of threatening figures. 1 in cases which seem to belong to this group. which are as often sung as spoken. and troops approach. rhymes. . they are no longer at home. is present in one- Unfortunately but few cases Anatomy. . They have been tried in court and are awaiting their death sentence. the content of speech They become noisy and shows great incoherence. in cathedrals.

even to bathing and obeyed .EXHAUSTION PSYCHOSES 87 ing that they have a mission to perform. They prattle away incessantly. overturn furniture. little nourishment. Occasionally is prominent with exhibitions of passion. . however. The^condition of nutrition is very and there is a marked loss of flesh and physical weakness. are about to give a large dinner. may predominate the emotional tone. pound the door. Physically. or are on the of way to interview the President. In emotional attitude they are much exalted and sometimes^eroticy especially in . and there is some tendency is to acute decubitus. the temperature usually subnormal. now at the top of their voice. The attentio n cannot be attracted. their whole activity seeming to be lost in a mixture of confused impulses. they are possessed immense wealth. and the pulse weak and irregular. They are destrucVery often they indulge in the most tive and untidy. are usually exaggerated. race about the room. The reflexes Tremor is sometimes present. there sleep at all. If the patients only for short intervals. Questions asked are rarely answered. Likewise they cases take but poor. in many requiring mechanical feeding. the condition rarely lasting over . irritability The motor excitement is very pronounced the patients remove their clothing. it is is great insomnia. and try to get out themselves. reckless and impulsive movements. Orders are not on the other hand. sometimes in a whisper. puerperal cases depression with anxiety. The course short. they almost always exhibit a ' purposeless resistance to everything. are married and have given birth to children. following the onset and during the height of the disease. and again gesticulating and clap- ping their hands. throw the bedding out of the window. dressing. The skin is cool and pale.

in the absence of a ' *• history of previous attacks. which are usually of a religious nature are moreiantastic and terrifying. the weight increases rapidly. The^attention can be held and short coherent responses obtained in delirium tremens. and the movements are far more ^stereotyped. On the other hand. The delirious exDiagnosis. The return to consciousness is usually sudden. One can only say that the latter is characterized by a greater disturbance of apprehen- . some exaltaThere is also a tion. As they begin to take nourishment. in citement of dementia paralytica can be differentiated only by the history of preceding mental deterioration. disorientation. the patients awaken. grumbling. is very difficult to distinguish from collapse delirium. rarely follows exhaustion. The delirious mania of manic-depressive insanity. and fretful manners. perhaps showing a flight of ideas. the presence of undoubted physical signs. the hallucinations. the condition of motor excite- ment disappears gradually. they the hallucinations and illusions are conscious of their surroundings and ask for nourishoften following a sound sleep. ^Relapses are rare.FORMS OF MENTAL DISEASE Hwo weeks. is — Collapse delirium differentiated condition of epileptic dazedness. by the presence of flight of ideas and aimless impulsive movements not associated w ith id eation. and the^extreme extravagance and absurdity of the delusions. desire physical weakness with the to remain in feeling of bed. have disappeared. The condition of catatonic excitement is of more 'gradual onset. with only slight disorientation. which is impossible in collapse delirium. which may be confused with this condition. from the which there is confusion. the consciousness is comparatively clear. The patients continue to be talkative. and many hallucinations. When ment. animal shapes being present. In delirium tremens.

89 Amentia prognosis is differentiated by the longer course and Death occurs in a especially where the the distractibility of the attention. and may minutes to one and even several hours. hundred to Also infusion of (five warm normal salt solution. The bath should be given eight to one hundred degrees. or breast. The patients may Hypnotics are usually bath. be given under low pressure in the back. few times. hibits fear in getting into the bath from fifteen During this time last If the patient ex- and requires holding. "Siutrition result of collapse. The is quite favorable. or sulphonal. 2^ to 3-| ff grain. The best means of inducing quiet is by means of a proat ninety- longed warm bath. hot . with the bath for the first even fall asleep in the bath. few cases as the Treatment. cold cloths must be kept on the head. membrane. espeThe infusion should cially if there is impending collapse. one to two pints one thousand cubic centimetres).'^alcohol is contraindicated. Broths and peptonized meats may be added in small quantities. to accom- which it is often necessary to resort to forced feeding by stomach or nasal tube.EXHAUSTION PSYCHOSES sion. — The important indications are to maintain and to reduce excitement. give excellent results. The patients must receive a sufficient quantity of light liquid diet. In such cases one may give a hypodermic injection othyoscine hydrobromate. Where plish mechanical feeding is contraindicated because of vomiting. or abrasion and hemorrhage of the mucous nutrient enemata can be substituted. given in doses of one to two ounces (forty to sixty grammes). Alcohol in combination with milk and egg is extremely valuable. exciting cause has been very severe. fifteen grains. rump. Next to the of the most service in producing sleep. in combination the bath can do but little good. In collapse.

Pathological Anatomy. delusions. consisting of thus far reported. While these more or less disintegration of the Nissl granules and staining of the achromatic substance. or rectum. Acute Confttsional. It is necessary that the patient be isolated in ' a place where there is quiet. Insanity (Amentia) is by the sudden appearance of dreamy confusion with numerous hallucinations. they cannot be regarded as pathogno- . and motor excitement. which should always return to . or digitalis are indicated. — The etiological factors are similar to those in collapse delirium. present widespread cellular changes in the cerebral cortex. — The post-mortem observations. are almost always present. Constant attendance must be enforced in order to prevent injuries. warm baths. normal. the patients must have completely recovered before being permitted to take up their former duties.. Finally. During convalescence the same indications obtain here as in convalescence from any acute disease careful feeding. Etiology. and sufficient attendance to keep him a- in bed. in which alcohol should be employed. and this must be observed until convalescence is well established. and running a favorable course of two or three This psychosis characterized months' duration. except that typhoid fever and anaemia are more frequent causes. lesions. 90 coffee FORMS OF MENTAL DISEASE by mouth. A good index of this is found in therweight. both with and with- out extensive involvement of the nucleus. and freedom from all forms of excitation. following a condition of severe exhaustion. strychnia. Mechanical restraint should be withheld padded bed or room is preferable.

restless. and will send an army to Cuba. and it is usually possible to direct the train of thought by objects . Symptomatology. the devil has secured them. as they occur in various somatic diseases. patients are unable to The do not ings. the home is lost. aj^ehend correctly. In the course of a few days. and lose track of time. At first the patients are / anxious. and they do not recognize their relatives. are dead. Their sur- roundings seem changed. they have been around the world. will convene Congress. they all know where they The are. and inability to gather their thoughts or — concentrate their attention. and forgetful. lions are roaring. are*'hallucinations of all the senses. sometimes complaining of numbness and confusion in the head. and often repeated. with and perispaces.EXHAUSTION PSYCHOSES monic. The patients see strange faces and hear strange voices. Sometimes they^fabricate extensively. and beginning hyaline changes in the small cerebral vessels. attention is attracted to tbe surround- they endeavor to grasp what transpires. there has also been noticed hyper- emia of the infiltration of leucocytes into the perivascular cellular meninges and of the brain substance. mistake friends. 91 Besides the cytological changes. the confusion increases and there There is -'complete disorientation. birds are flying about. illusions appear. which are dreamy. and they are threatened and cursed by strangers. contradictory. possessed of great wealth. incoTheir children herent. are under the influence of some magnetic power which draws them about. poisonous powder is thrown at them. and in the end will consume them. In a few cases the delusions are expansive they believe themselves exalted to some high position. . they are to be hung. The numerous hallucinations form the basis for many depressive delusions.

The are disturbance of thought is very prominent. usually of persecution. To some of these patients everything is changed. sometimes with prevailing happiness. They move about restlessly. and complete inco- thought. mirthful. are caught They quite unable to express one thought before others interrupt. Often the content of speech incoherent. '^Alternations of the attitude are c haracterist ic . herence. they are being served with different dishes. In spite of^distractibility^ight of ideas. single. The is con- sciousness is much"clouded and dreamy. crawl in and out of bed. by movements and gestures yet they cannot understand readily even the simplest occurrences. the chairs and win- even the nails in the floor are changed. for short periods they may be elated. The persistence/ of clouded consciousness during quiet intervals acteristic feature. but the actions are not very quick. one occasionally finds the patients holding to single indefinite ideas. held before them. a char-j The emotional attitude varies considerably.92 FORMS OF MENTAL DISEASE . though the train of or directing is made up of and disjointed words and phrases. the papers are incorrectly dated. Words and sounds influencing surroundings and find a place in their not necessarily up from the expression. things to-day are not the same as yesterday. the strokes dows are different. and hilarious. of the clock are not right. perhaps some stupid. destroy clothing. sexual when they suddenly become excited and irritable. but more often with depression. are performed without . or they may be even dull and In the psychomotor field there is a marked tendency toward 'great activity. with excitement. Occasionally sound associations and rhymes are heard. pound and beat.

and occasionally indefinite irritability. From that time the symptoms present a rather characteristic fluctuation. Other physical signs are increased deep reflexes. and protracted. incoherent. In show some constraint. and the thoughts become coherent. long conversa- tion or letter-writing tends to develop mental confusion. expansive or depressive actions they will delusions are expressed. may be haughty and reof the disease Even after all the symptoms have disappeared. or they served. — The height of the disease is reached within two weeks. when great motor excitement is present. even after the patients have become clear. the sleep intermittent. or in distrust. and subnormal temperature. Genuine improvement develops gradually^ First the motor restlessness disappears. is is £.EXHAUSTION PSYCHOSES 93 much energy. and outbreaks of passion. and sometimes there especially complete refusal of food. a few hallucinations may persist for a short time. or where the patients entertain ideas of distress. irritability. when the patients again develop excitement with complete incoherence of thought. slow pulse. anxiety. — much is disturbed. the appetite poor. Then the patients become^oriented. is This motor excitement Physically. thoughts and express themselves cohe- Even after they have become clear. seen in hyperactivity and garrulity. during which time there may have been transitory Remissions with clear consciousness and insight. The motor excitement may disappear. even while there still remains great incoherence. . During the first few weeks of the convalescence the emo- tional attitude may show and a slightly elated or depressed condition. are planl ess. are able to gather their rently. The entire course extends througlrthree to four months. the patients are very apt to show diminished . Course. In some severe cases.

psychosis rarely leads to Death rarely occurs. power and rises excesses are apt to create relapses.94 FORMS OF MENTAL DISEASE of resistance. due to collapse. The condition of is catatonic excitement distinguished by the fact that the catatonic patients in the midst of the greatest excitement are usually able to comprehend and besides . Diagnosis. they present the characteristic catatonic signs namely. and motor excitement. while in the maniacal state. patients are still when they have quite disappeared. more in quiet intervals. In amentia the move- ments are slower. clear spite of the ability to maintain the attention. heart failure. This permanent mental impairment. planless. The prognosis is favorable. greater susceptibility to fatigue. in spite of great motor excitement. and stereotyped movements and manners. their surroundings. sepsis. — In differentiating this form from other psychoses it is necessary to bear in mind the causal condi- tion. From amentia the maniacal form of manic-depressive insanity. profound disturbance of \ thought with confusion and sometimes flight of ideasj/ changing emotional attitude. delusions/ and hallucinations. and to record some passing events . negativ- ism. the former of which persists even after the motor excitement has in a great measure subsided. namely. mutism. is distinguished by the much greater prominence of the disturbance of apprehension than of the psycho- motor sphere. catalepsy. the patients usually give evidence of at least a partial comprehension of the environment. The weight rapidly during convalescence. . distractibility. -^exhaustion. this. of and the characteristic apprehension in symptoms . and less precipitous. to recognize persons. verbigeration. to reckon time correctly. and. — the acute difficulty onset. and is and phthisis. the hazy and confused.

hallucinatorischen Wahnsinn. Psy. Amentia. Meynert.. 1881. Willie. Studier over primar idiopathish Amentia.. 1897. 1. Ueber die Pathogenese u. Psy. 1890. . sional doses of hyoscine. H. bromides. Meynert. XIX. f. S. consisting of forced rest in bed and prolonged baths to Occa- induce quiet. aided by moderate doses of alcohol. klinische Stellung der Erschopfungspsychosen. 1895. Wochenschr. ( 24. XLII. Allgem. La Confusion Mentale Primitive. or paraldehyde in extreme excitement are of value and better tolerated than in collapse delirium. Berlin. trional. Lehre von Verwirrtheit. Paulsen. Zeitschr. Archiv f. Zum Sog. 2. BIBLIOGRAPHY Binswanger. klin. Klinische Vorlesungen ueber Psychiatrie.. Die 329.' Mayser. 1896. Nr. sulphonal. f. Psy.EXHAUSTION PSYCHOSES 95 The treatment coincides with that of collapse delirium. Chaslin. Amentia. 23 u. Jahrb.

Acquired neurasthenia. as used here in a restricted sense. mental application. which transitional states is here considered as one of the constitutional psychopathic states. and a great variety of physical symptoms. must be clearly distinguished from the congenital or hereditary neurasthenia of the French authors. offatigue. condition of chronic nervous exhaustion is the con- result of excessive It is mental application continued for some is one of the products of civilization. The difference in the train of symptoms. exhaustion are both it seems. Etiology. with little relaxation wholesome sleep in and extravagant manner and lack of sufficient and individuals actively engaged in busiirregular. and fined largely to the professional and clerical callings. No and doubt there are external many between the two diseases. includ- ing hypochondriasis. — Rapid. their course and outcome. of living. in individuals free from hereditary taints. American in the temperand accounts for the greater prevalence of 06 . defective It characterized by increased sense irritability. are sufficiently distinctive to justify this restric- tion of acquired neurasthenia. is ness or taxed with the responsibilities of the household distinctively characteristic of the ate regions. is and to women of the middle classes.ACQUIRED NEURASTHENIA Chronic Nervous Exhaustion The time. and especially where defective heredity prominent factors.

but is apply themselves too closely to studies without relaxation. when the with absence of the usual sympathetic feelings. the period of life during which there is the greatest mental strain. It most often met between the ages of tw enty-fiv e to forty-five. one sometimes meets the opposite condition. sluggish and sleepy. The capacity for mental application diminishes rapidly. Besides excessive mental application. are easily distracted by little things and are inatten- Twice the usual time still is spent in reading the paper. columns of figures have to be added several times before the correct and J . and figures. At an earlier age it is seen in ambitious students who all ages. requiring greater exertion and more frequent rests. stupid and dull. — The Trivial matters may lead to outbursts of passion over which they have no control. keenly appreciated by the patient. They tive. Instead patients are indifferent. They are forgetful with names. Neurasthenia occasionally appears after a seve re mental: shock. il lness or symptoms in both the physiand psychical fields are equally prominent. the first to appear is irritability. of the children irritate At home the frolics them beyond endurance. of these signs of irritation. at the beginning overcome by the will. and overcome with an irresistible drowsiness. the worry attendant upon responsibility appears at is an important factor. It is almost as prevalent among Russians. but under stress of excitement always coming to the surface and causing annoyance. The accustomed work~is carried out with increasing difficulty.ACQUIRED NEURASTHENIA this disease in 97 our people. The patients are very easily irritated. cal ing. they are unable to get an idea of its contents. become unreasonable and fault-findSymptomatology. Of the mental symptoms.

nate and create disappears. The physical symptoms are even more strongly exaggerated. The appreciation of their incapacity creates a feeling of reserve. assert that the memory is becoming profoundly affected. and that the judgment is failing. It rarely happens that the feeling of despair becomes intense enough to lead to suicidal attempts. Canker in the tion of their health leads mouth is considered infallible evidence of syphilis . The trend of thought in a letter or conversation abruptly broken off and forgotten. Associated with the loss of will-power. of the patient. which sometimes explains the . but the real symptoms are greatly enhanced by the habitual attention paid to them. that they are succumbing to consumption. apprehending fainting spells on the slightest exertion. a cloudy urine indicates Bright's disease. and especially the one which they have most dreaded. timidity. There is not only a keen insight into these defects. may be much The to the chagrin ability to origi- who tries to continue. but They also a tendency to exaggerate the real symptoms.98 FORMS OF MENTAL DISEASE is sum obtained. They cannot trust themselves in public. and a lack of self-confidence. and a cough. which aids in increas- ing their misery. The in excessive anxiety about the condi- to a characteristic symptom. The patients believe that they are suffering from some incurable disease. hypochondriasis. There may be some genuine disorder. which there is a tendency to pay undue attention to trifling symptoms which may appear in any organ. there should also be mentioned the tendency to compulsive thoughts and impulsive acts. to recall the They are embarrassed by their inability names of well-known acquaintances. and the patients find themselves confined to that which is purely routine in thought and action.

headache. roaring in the is painful pressure points in the scalp. fully described in the constitutional psychopathic strife to In the ideas. tigo. sias or . a feeling of numbness or a pressure in the head. obtained either in the early immedi- morning. and increases with exertion until it becomes unendurable. or The . It is more prominent in the mornSometimes there is a ing. and gastro-intestinal disturbances. may be expressed as a headache. general muscular weakness. ACQUIRED NEURASTHENIA suicidal attempts. with restlessness. paresthesias.. eyes or in the occiput. Subjective sensations are prominent. usually an aggravating symptom from the ately of The few hours upon retiring. evidence general muscular weakness always in they are always languid. are unrefreshing and by dreams. held in a vice or thehead were if as pressure. which This is usually situated over the interferes with work. These states are more apt to follow continued excitations. passing off during the day. and tire easily upon walking or from slight muscular effort. crying and moan- and even attempts at suicide. after hours disturbed is restless tossing. overcome impulsive crisis of which are states. Insomnia onset. of feeling by a constricting band. the pa- tients often reach an emotional of the short duration. hands. Physical symptoms form a very characteristic feature The most important symptoms are of the psychosis. such as paresthea feeling of formication in the trunk and limbs. 99 Here are included the various phobias. wringing ing. cardiac alalgia. insomnia. or dimness of vision. It may be associated with verears. Cephwhich appears early. Both the superficial and deep reflexes may be increased rhythmic twitchings and tremor are occasionally noticed. such as prolonged visits or unusual noisiness. of sleep.

cold extremities. demand the utmost consideration for every whim. the patients become chronic invalids of a most distressing type. with occasional precordial pain. stomach accompanied with Extending into the intestines. the latter of which uine colic. is by far the most prominent digestive disorder. They go the round of physicians. there may The be vasomotor disappetite order. but the nervous dyspepsia. the severe enough to simulate genis fermentation gives rise to borborygmy and colicky pains. there more often a loss of sexual but in a few cases a tendency to excessive indul- gence. causes distention of the frequent. They betake themselves to the seclusion of a charitable institution with its freedom from annoyances. localized sweating and blushing. taking all kinds of drugs. All attempts at business are abandoned. Mentally they pass into a state of lethargy in which all thought centres about their own misery. but in severe cases it may even cause cachexia and anaemia. or abnormal dryness of the skin. and Diarrhoeas are apt to appear for persistent for a considerable time. gastric discomfort and pain.100 FORMS OF MENTAL DISEASE cardiac disturbances are palpitation and The prominent irregularity of the action of the heart. They . In cases which resist treatment. especially hydrochloric acid. The intestines are usually constipated. is may be life In the sexual desire. although at the same time patients complain of impotence. Associated with the cardiac disturbances or occurring independently. maybe The digestion usually not impaired suffici- ently to create disturbance of nutrition. is variable and anorexia is and intestinal. short periods. Gastric fermentation. and the cares of the household are renounced. probably due in part to deficiency of the digestive fluids. or if they remain at home. pass from one sanatorium to another.

Course. The psychoses which may be confounded with neurasthenia are dementia paralytica. dementia prsecox. and upon demand they are able to . doc- am dying Just feel of my abdomen. after a paralytica arise only in the first stages of the disease. Patients with a strong sometimes extending over years. especially influenza. It is this class of tor. in order to assure the physicians or friends that they are in a critical condition. and when received at the hospital from the hands of a tender-hearted mother. Have you no compassion for a dying man ? " A female patient remained in bed for years. The increasing demand to various for sympathy leads to prevarications and assumed contortions. It may appear suddenly. A daily improvement toward evening is noticeable. There is a great variation in the prominence of the symptoms. chloral. health. and one of her toe nails had grown to the length of five inches. antipyrin. . neuropathic heredity rarely recover the former state of Diagnosis. The diagnosis of neurasthenia should be reached by a process of exclusion. is The usually protracted and the convalescence gradual. cocain. pull themselves together for a special occasion course but the follow- ing day witnesses an exacerbation of the symptoms. — It is of prime importance to exclude all organic disease of the internal organs. is of the disease gradual. following an acute disease. The daily greeting from one patient was. and The difficulties in dementia melancholia of involution.ACQUIRED NEURASTHENIA 101 have no thought for the maintenance of the family or appreciation of the burden which they create. — The onset and other drugs. had not had her hair combed in two years. most thorough physical examination. I ! patients who eventually become habitues of morphin. " My God.

increased myotatic irritability. The prodromal periods of the other psychoses. or appear in neuropathic individuals who have succumbed in the struggle with more favorably endowed associates. The appearance of apathy without sufficient cause. Individuals who by a defective heritage must be . which is so day to and does not show the characteristic of the memory tal in the paretic. The ence of the characteristic nervous paretic leaves disturbances of the Argyl Robertson pupil. The sensory disturbances of neuraspres- theniac are subjective. and of delusions of reference or persecution without insight. indicates the more serious condition. are hardly to be distinguished. Neurastheniacs complain of men- impairment. the chances for permanent improvement are poor. tremor of the muscles about the mouth and of the tongue. In neurasthenia the day. but are able to amend errors in writing and speech.102 FORMS OF MENTAL DISEASE Signs of nervousness without definite cause in a man of healthy constitution appearing for the life first time in middle should at least arouse suspicion of dementia paralytica. depends upon the extent to which the exciting causes can be removed. the duration of the prognosis The and the neuropathic basis. ataxia in speech and gait. while the apparent mental defect in the is paretic unrecognized. Where possible. its extent the is not appreciated. it is the duty of the famdisease. especially where these psychoses follow some acute disease. Treatment. objective. of the paretic. Unless the patient can be removed from the exciting causes. especially dementia prcecox and melancholia. if recognized. — ily physician to bear in are handicapped mind prophylaxis. and no doubt : epileptiform or apoplectiform attacks. is memory defect varies from easily corrected defective time element upon effort. or.

the prolonged warm Of these the most serviceable methods are baths. with a cold towel about the head. or where is impracticable. Isolation with a changed routine of life demands immediate attenIn the lighter cases.. mountains or a sea voyage to relieve the this asthenic condition. cold ablutions. with due attention to moral and physical hygiene. But before ing to these medicinal means. is wound dripping about the patient. hydriatics should be thor- oughly tried. grees for thirty or forty-five minutes. together with the avoidance of worriment and anxiety. after a cold ablution. ACQUIRED NEURASTHENIA 103 well guarded during their development. one Usually the change of the surround- ings with different routine relieves this condition. the simple douche. a linen sheet. the spray. Next to isolation. ninety-eight to a hundred deand the dripping sheet. but attractive place. when it becomes necessary to enter actively into the severer duties of life. removal from the customary surroundings into a quiet. In the treatment of the disease after is the individuality of the physician of its development. the patient standing in warm water. modern resort- hypnotics. or on a dry surface. eighty-five to seventy-five degrees. must be constantly kept in mind. sulphonal and trional. It requires confidence in order to inspire the patient and to utilize his power lift him from his morbid anxiety and depression. insomnia must be combated. restful. the limitation of mental application and physical exertion. case this fails. dipped into water seventy-five to fifty-five degrees. Later. a trip to the tion. prime importance he must recognize and of influence over the patient in addition to various therapeutical agencies. last In the method. In may use alternately the various etc. will accomplish the same result. which may be carried out at home. the nurse at the same time applying friction .

Electricity is ment called for in correcting uterine troubles. but requiring of all a definite amount of sleep. In the more severe cases. together with life. baths and out-of-door All of this may who be carried out is under the supervision of a physician relative willing to spend time and thought in caring for the details. errors of optical refraction. together to the tastes.104 FORMS OF MENTAL DISEASE The douche. is of great value. The anaemic and debilitated who have been exhausted by long suffering or the prolonged care of with anxiety and worriment. alternated with rest and relaxation. require forced rest for a few weeks with a full nutritious diet. carried out at a bath institution. Where tion exists. which must be purposeful and suited somewhat invalids. . also. Sometimes local treatconditions. must depend upon the conindigestion or constipato counteract dition of the nutrition. or in removing nasal obstructions. but only secondary to the above methods. Others need daily exercise. the usual means should be used these always giving preference to physical and massage are of value. the secret of successful treatment a well-regulated routine suited somewhat to the tastes of the individuals. nourishment. as until a thorough reaction takes place. agencies. massage and passive movements. The in amount of exercise and forced rest must vary individual cases. mental and physical exerlies in cise. The diet.

often with conditions of ecstasy. dreamy fantastic delusions. which might be mentioned here is large. senses. according to the length of the time during which the toxic substances have been ingested. the term intoxication psychoses is here used in a narrow sense to include all psychoses arising from toxic substances taken into the body. however. The number of toxic substances. In santonin poisoning there are hallucinations of sight in which everything appears yellow hasheesh delirium is characterized by disturbance of the taste and muscle . with pronounced psy- chosensory disturbance. 105 . They are divided into acute and chronic intoxications. of great scientific value to investigators. including ptomaines. Acute Intoxications The acute intoxications are characterized in common by a delirious state of short duration. and without much motor excitement. They are. pleasurable emotional attitude. who are able to study pathologically and psychologically the effects of the different toxic substances. The transitory character and the infrequency of the toxic deliria make them of little importance to the clinician.INTOXICATION PSYCHOSES As already stated. The mental state produced by chloroform is characterized by hallucinations of sight only. are characterized by peculiar mental Some of these which symptoms will be mentioned here.

many delusions with great fear. and poorer prognosis. and complete clouding of consciousness. The duration of all these conditions is short. tremor. pleasurable existence. The psychosis produced by lead poisoning.106 FORMS OF MENTAL DISEASE feel- Hasheesh and opium smoking produce a complacent ing of well-being. is incoherent. The prognosis depends entirely upon the severity of the intoxication. is a severe disturbance of apprehension. characteristic nervous symptoms. The carbonic acid narcosis is characterized by its short duration and the presence of pronounced sexual hallucinaIn the toxic condition produced by atropin there tions. great psychomotor disturbance. and of a dreamy. There are many hallucinations of sight and hearing. with isolated hallu- cinations. pathia satuminia . and sometimes colic. The immediate prodromes are restlessness and headache. attitude. The course is fatal or the psychosis clears very quickly with no recollection of the events. elated emotional and active motor excitement. In diagnosis one must rely in great measure upon the knowledge of the circumstances and upon the physical signs. peroneal paralysis. The physical symptoms usually precede the mental disturbance that is. from a few hours to a few days at the most. and in the height of the delirium there are frequent reckless impulsive movements. and very little nourishment . The speech is There complete insomnia. The onset of the delirium may be acute or subacute. and the application of special antidotes. wrist drop. encephalois more frequent and differs from the above delirious states by its longer duration. The treatment is limited to the employment of means to rid the body of the toxic substance. either marked confusion of thought. pains in the limbs.

always been used first for medical purposes. An . The whole duration of the psychosis in favorable cases is from a few weeks to three months. upon regaining clear consciousness. coma. A few present progressive muscular atrophy. sometimes antedated by stupor with and ambly- excitement. those best whose continued use leads known and of most Almost clinical value are alcohol. Epileptiform convulsions opia is may also appear. anthropological have according to data. had a nations. The active excitement is followed by a condi- tion of stupor or coma. because of its close association with chronic alcoholism. morphin. extend- ing over several weeks. all drug whose habitual use has been a source of danger to its It is a striking fact that these substances have people.INTOXICATION PSYCHOSES is 107 taken. tion of Acute alcoholic intoxication produces at first a diminuthe power of apprehension and elaboration of external impressions. and cocain. The perception sluggish. and later continued for their exhilarating and alleged supportive toxic substances effect. and an acceleration in the release of voluntary impulses. there are many who. of simple sensory impressions is difficult. and uncertain. Some cases terminate fatally in While most of the patients recover. The convalescence gradual. present a degree of mental enfeeblement in which simple apathy is a prominent feature. is frequent. simulating dementia paralytica. Chronic Intoxication to disturbances of the mind. Of the many Alcoholism The acute than under intoxication of alcohol is described here rather the acute intoxications.

He has no conception of the significance or the bearing of his actions. a light grade In the psychomotor straints field. Even small work. and sometimes already The release of executed before the proper direction displaced is determined upon. frequently incorrect. A thoroughly intoxiunable to comprehend what is said to him his attention what goes on about him. Thoughts are not complicated problems very This increases with the cated or man is amount taken. the psychomotor activity is by paralysis. the rapidity paralysis depending both susceptibility of and extent of the upon the amount taken and the the individual.108 FORMS OF MENTAL DISEASE attempt to solve a simple problem shows a distinct diminution in intellectual power. The choice between two movements precipitous. at first. with the disappearance of the usual re- which regulate the actions of our daily life. of over-activity. Later. such as the use of compound words and rhymes. or following larger doses. as indicated by the tendency to the repetition of phrases and the use of commonplace remarks. events of the intoxicated state is The memory there is of the very meagre. soon much diminished. solution of doses influence the capacity for good mental easily gathered. In speech one can discern that the association of ideas most closely related to the motor elements of speech is prominent. also in the fondness for quoting obscene rhymes and in the use of jargon. is at first slightly increased. cannot maintain or direct the train of thought. rendering the difficult. nal association of the train of thought is The interdis- very much turbed. He . The muscular strength. accelerated that that finds expression is is motor impulses is so much most readily which learned by heart. Finally apprehension may be so far lost that he becomes insensible and unconscious.

grumbles. and Fatigue predisposes to rapid appearance of Individuals anorexia. headache. the diminution in size and irregularity of the nucleus. There is a certain degree of exhilaration. aggressive.. seen in the fading and the irregular amalgamation of the Nissl granules. a staggering gait. The ready release motor impulses promotes the feeling of increased muscular strength. each action is exaggerated into laughter. and the smile broadens becomes profane. Later the motor excitation increases its the facial expression loses character. is often led to filthy excesses. and even complete motor paralysis. who are apt to be slug- gish and sleepy are apt also to be quarrelsome. as the disturbance of apprehension increases. of and jolly. and a freedom from care. paralytic signs. and with the increased sexual excitability. free restraint. He is shameless. Later irritability appears. He becomes light-hearted and happy. and growls. usually disappears quite although thirty-six effects may be observed for twenty-four to hours later. and there is a profound disturbance of speech. Finally the excitation. He is is louder. Nissl has demonstrated a profound change in the cortical neurones. the voice He trifling accident suffices to start a quarrel or to lead to an assault. gay. The duration the individual. The higher moral feelings are lost. INTOXICATION PSYCHOSES is 109 active. nausea. hasty and passionate. lassitude. whose mem- . and even cruel. ill of the intoxication depends It much upon rapidly. and even without the intervention of the period of excitation. As the result of experimental investigations of acute in- toxication in test animals. is replaced by signs of paralysis. mischievous. speaks and acts without and even becomes reckless. and a single word or a . The emotions at first give way to a feeling of well-being.

of cases with defective heredity. The cerebrum is below normal in weight. Dehio has observed similar changes in Purkinje Chronic Alcoholism Chronic alcoholic intoxication is characterized by gradual and progressive mental deterioration. of the small terminal arteries of the cortex. but the most characteristic lesion is found in the endarteritis. depending pathologically upon a chronic degenEtiology. The extensive use of alcoholic drinks by many classes of it people and the laxness of public sentiment in regard to should also be considered as an etiological factor. manifested by a diminished observers have reported as power of resistance. in test animals. Nissl. cells. lesion is The is principal arterio-sclerosis. — The pathological lesions found in chronic alcoholism are equally prominent in the central nervous system and in the internal organs. and other parts of the brain. The larger vessels at the base and in the fissures pre- sent arteriosclerotic patches or atheroma. in his experimental research with chronic alcohol- ism. The the cortical neurones present what Nissl has called chronic change. mostly localized. and its ventricles dilated. there regularly more and pachymeningitis with or without haematoma. a gradual sclerosis.110 FORMS OF MENTAL DISEASE brane and nucleolus may finally disappear. many physical symptoms. Some high as eighty per cent. Pathological Anatomy. In the brain. with erative process in the central nervous system. found a moderate thickening of the . the ependyma of which in rare or less chronic leptomeningitis instances is granular. its convolutions more or less shrunken. etiological — Defective and heredity is is the most prominent factor.

The power mental application gradually fails. fatty in- filtration of the myocardium.INTOXICATION PSYCHOSES pia. which the impairment of memory and of the moral sense is most prominent. it Their depravity is is disregarded with a nonchalance. Symptomatology. and the patient soon loses sight of the higher This is especially ideals of life and the sense of honor. and the sense of fatigue New and unaccustomed work requires unusual increases. showing an increasing lack in judgment and a poverty of ideas. chronic nephritis. enhanced by a gradual failure of memory. taken for their physical benefit. noticeable in their estimation of their own alcoholic habits. This con- dition offers a fertile soil for the development of more or less pronounced delusions (alcoholic paranoia). Consequently intellectual progress not only ceases. the other organs are chronic cirrhosis of the liver. in The gas- usual alterations tritis. There is a profound change in moral character. but retrogrades. and chronic endocarditis with greater or less degree of general arterio-sclerosis. The moral deterioration is a prominent and characteristic symptom. and are indifferent in applying themselves to any mental work. with an increase of neuroglia. The enfeeblement of the intellectual in intellectual capacity of the man is first to suffer. application and is accomplished only with difficulty. destruction of 111 many of the cortical neurones. Finally there is inability to acquire anything new. or claimed that the liquor. especially at the base. There also develops a failure of judgment and diminution in the capacity for employment. is important facts are forgotten. — There is a gradual and progressive faculties. . of difficult to Patients prefer to continue in the same old ruts. it becomes maintain the attention. and the past as a somewhat confused and recalled only distorted picture.

he shows no feeling of shame. engage in strife and abuse on small provocation. Patients are quarrelsome. and an ugly wife are frequent incentives. the fireman. Many are driven to drink by unfortunate circumstances at home the death of a relative. the truckman. misuse their children. and are destructive of clothTheir complete and abject submission ing and furniture. Their inand attitude of humiliation before others often excites sympathy from the inexperienced. because of while the night watchman. wives. disregard the real infidelity of their wives. become indifferent to the tears of their children. at the same time developing a certain exaggerated feeling of self-importance. have little inter- est in their welfare. noticeable especially in conversation. they accuse a friend of having given liquor. offensive behavior . when opposed by a superior force or when incarcerated is in marked contrast to their behavior at home. and display an unnatural sense of humor [drunkard's humor). a sick child. which is more evident during intoxication. or claim that they are driven to them the drink by their . A faithful promise to abstain from further use be volunteered by an habitue but when day later he is encountered coming from a an hour or a saloon. and the iceman need it to drive off the cold. and the iron moulder require . The patients lose all affection for their families. They are unable to take matters seriously. others It is as can be regarded as a food. does When reprimanded for continued inebriety. 112 FOKMS OF MENTAL DISEASE them no harm. There is a corresponding increase of mental irritability. of interest to note the variety of conflicting excuses offered for the necessity of taking liquor it : the cook. of alcohol may Some claim that take only as much by mechanics the great heat their work needs stimulation ..

234. S. with occasional aphasic symptoms frequent headaches and sometimes vertigo. They leave the sup- port of the family to the wife and children. field there are frequently areas of hyperaesthesia and an1 aesthesia. in Wiklermuth has recorded them only one and five-tenths per cent.. They are more fre- quent in persons who have been addicted to distilled liquors. offering the excuse that they are physically unfit for continued labor. regarding it simply as epileptoid. Prognosis. of cases. rarely permanent. . rarely lost. sometimes thick. Epilepsie. similar to the convulsions occurring in uremia These epileptic attacks are and dementia paralytica. The most prominent physical symptoms — are fine tremor. INTOXICATION PSYCHOSES 113 They become visit entirely unstable.. The tendon In the sensory reflexes are often increased. 1899. Wartman. — The chances of recovery depend upon the extent of mental deterioration and the character of the If the patients already show moral deteriotreatment. Psy. from saloon to other. prolonged treatment 1 is apt to be of f. sometimes slurring. defective speech. Magnan. each Bratz. Alcohol u. and others believe that it is to be distinguished from true epilepsy. Physically. Allg. Epileptic attacks appear in from one to thirty five per cent. Others degrade themselves by pawning clothing or furniture. cannot remain at borne. or even steal in order to satisfy their appetite. saloon. little avail . usually disappearing with the withdrawal of alcohol. first in the finer movements and muscular weakness with atrophy uncertainty in gait. whom they browbeat for enough money to keep them in liquor. noticed later becoming general . Zeitschr. and engage in tramp from one city to an- their usual occupation only for a few days or hours at a time. ration. varying according to the observations of different investigators.

. and the physical symptoms. — The successful treatment of chronic alco- holism demands complete abstinence from alcohol in every few patients are capable of carrying out this injunction successfully by themselves. becoming at last mental and physical wrecks. institutions fair pros- In many reputable inebriate of from one-fourth to one-third their cases recover permanently. An index of the power of resistance may be found in their insight into their own condition. Cases when taken early and submitted to an extended treatment have a pect of complete recovery. which progresses gradually. require the treatment afforded by a special institution for alcoholics. The alcohol can be suddenly withdrawn except in a few cases where there is A a disturbance of the\heart. and occasional hallucinations which arise in consequence and in a few days improvement begins.114 FORMS OF MENTAL DISEASE time they relapse into their former habits. cases require a hospital residence of nine to twelve months. but the vast majority. Treatment. and especially those whose occupation brings them into bad associations. sents — The recognition of chronic alcoholism pre- few difficulties in view of the history. The alcoholic psychoses which develop upon the basis of chronic alcoholism are : delirium tremens. The insomnia. Diagnosis. or even longer. anorexia. Severe of withdrawal quickly disappear. alcoholic delu- sional insanity. the typical facies. gestion has been an efficient Hypnotic sug- means in the hands of some physicians in bringing about a more rapid recovery. and willingness to prolong their hospital residence. form. the latter being at times made more evident by the presence of neuritic symptoms. alcoholic paranoia (Eifersuchwahn) and alcoholic pseudopareses.

produced by a condition use of alcohol. in . of acute alcoholic intoxication interferes with the belief is due alone to alcoholic intoxication. In view of these facts it is now the prevailing belief . The fact that the symptoms that it of delirium tremens in no way resemble those Further. 115 . Etiology. often of a religious nature. pneumonia. mostly of fear and apprehension. especially Other exciting causes are shock. that it arises as the result of an intoxication. with clouding of consciousness. and in some it appears in spite of continued drinking. rapid course and good prognosis. beIn this gastritis plays an important fore the outbreak. suffering r61e the patients from anorexia. and even weeks. the patients as.DELIRIUM TREMENS Delirium tremens is characterized by trie sudden development of fantastic hallucinations of sight and hearing. indefinite and changing delusions. and gastric pains. — There is an undoubted relationship between delirium tremens and chronic alcoholism. especially in individuals addicted to distilled liquors. attack seems to bear no definite relation to cases. The most important factor is a state of defective nutrition. of alcohol ingested the amount immediately before the it. which usually exists for days. some have had no alcohol for weeks its others develop the condition only upon withdrawal. injury. take little or no food for days. of faulty assimilation and metabolism in organs already made susceptible by the long-continued and acute diseases. vomiting.

especially beneath the central convolutions. There are often found small hemorrhagic points in the pons about the nuclei of the ocular muscles. vacuolation of the cell substance. V. u. there is present in severe cases an exstasis. that is. chromophilic attention to the dissolution of the producing a finely granular appearance. confined mostly to the posterior columns of the cord and their intensely stained for nuclei. staining of the achromatic portions. and to extent in the anterior and lateral nerve tracts of There is little or no alteration in the parietal the cord. 265. while there is no nervous lesion characteristic of delirium tremens.. the cortical cells usually give evidence of 1 Bonhoeffer. . Bd. Besides the acute changes. The cell alteration is of an intense degree correspond- He calls ing to the severity of the clinical symptoms. Bonhoeffer claims that. seeming to indicate that the degenerative changes in the cerebellum are associated with the centripetal fibres. S. and the various transition forms. — There is usually pronounced x venous and edema of the brain. and to the change in the contour of the cell body. The lesions characteristic of chronic alcoholism are also found. The manifold changes in the same brain. to the alteration of the staining qualities. Nissl has called attention to certain cell changes which remind him of the acute changes . is an accumulation of glia cells about the nerve The protoplasmic processes are some distance from the body.116 FORMS OF MENTAL DISEASE Pathological Anatomy. tensive degeneration of the nerve fibres in the corona radialis. f. There are degenerative changes in the pons and medulla. especially in the neuraxones. make it impossible to point to any change as characteristic. a less and Broca convolutions. Monatschr. Neur. and a moderate swelling. Psy. granules. There cells.

The most prominent symptom is tions of all the senses. and mur- . especially of sight numerous hallucinaand hearing. troops file by. patients constantly. There may have been a few indefinite hallucinations at night. are cursed. and huge Crowds press upon them. insects cover their food. produce a alteration in the emotions. a changed disposition. and light specks before the eyes. marked The patients see all sorts moving about them. disorientation. ringing of children. serpents crawl over the bedding. following a few days of insomnia and uneasiness. peering in at the windows or crawling from under the bed.DELIRIUM TREMENS chronic also 117 alterations. such as hyperesthesia. These appear in connection with clouding of consciousmore or less psychomotor excitement. They quadrupeds. large and small. In the internal organs there is found fatty degeneration and fibroid myocarditis of the heart. and certain motor and sensory nervous symptoms. and acute and chronic alterations in the kidneys. called traitors. indicative of sensory excite- ment. creeping sensations. thieves. The hallucinations and delusions. satyrs. and. an increase of glia cells and chronic vascular changes. They are perceived with great clear- ness. characteristic of chronic alcoholism. all sorts of noises : the roaring of beasts. unusual timidity. birds of prey hover about in the Fantastic forms are seen. and perhaps in- — definite sensory disturbance. mermaids. cirrhosis of the liver. are threatened with death. with the terrifying content. of animals. become more prominent. floor. Symptomatology. which appear first during the night. The onset of the psychosis is rather rapid. and his imps are omnipresent. crying of distressed They are taunted by passing crowds. and annoy the ness. The devil hear bells. rats scamper about the air. firing of cannons.

They can detect the dust is thrown in their faces. by directing the patient's and by asking them what they see and hear. 118 derers. is but more often. when there the former is a change of the emotions. in palatial quarters. ally there is Occasion- a mixture of the fearful and the beautiful. God appears to them. Hallucinations seen through a colored glass are not similarly colored. the tufts on the bedding become creeping things. and especially after the height of the disease has been passed. the bedposts cinations ture. FORMS OF MENTAL DISEASE Paresthesias of the skin lead to the ideas. are richly dressed. sulphur fumes are being forced through the Real objects about the room assume life. they are in beautiful surroundings. as the course of the disease progresses. Some- times the scenes are of a lascivious character. attended by lovely maidens. . in a The hallucinations and few cases. that ants are crawling over them. keyhole. and even the absence of wounds does not deter them from exposing limbs which have been shot full of Hot irons are being applied to their backs. and missiles. and empowered to cast out devils they are commanded to go to confession and to proclaim the gospel message . beautiful music is heard. passing show for the patients . and guards. they gaze at the hideous forms and listen to the various noises quite The results of various experiments seem to indicate that the hallucinations and illusions originate in disturbances of the central processes. announcing that they are Christs. Also the halluci- nations can be made to appear attention to their sensory fields. delusions. demon The content of the hallu- and delusions is not always of a terrifying naSometimes angels are seen. are nothing more than a unconcerned. that bullets have entered the body. gradually replaced by the latter.. odor of gas.

but they quickly relapse. various sensory There is defective interpretation of the impressions excited in the fields. do not recognize pictures. noticeable is when aphasic disturbances. which is especially times there Somethe type is small and indistinct. the patients complaining that the floor together. muscular sense. the temperature. no relation between the reading and the This same defect is sometimes due to subject matter. according to Bonhoeffer. there is a senseless to read. The disturb- ance becomes more apparent when the patients attempt Instead of correct sentences. difficulty. . remains normal . leading an orchestra. and the tactile sensibility somewhat sharpened. shrinking up or that the walls are coming Disturbances of apprehension are prominent. The field of vision is occasionally restricted. pain. when the patient is busy gathering up the gold lying about him. The sense of equilibrium and the perception of space is a little is uncertain. The attention of the patients is held only with great their attention. to obtain and are unable any sharp and clear impressions. may explain why their attention is not attracted to severe and how they can use broken limbs recklessly. There is always a moderate clouding of consciousness. with the result that the patients mis- interpret noises. The ideas which are excited by occurrences in their immediate injuries. It is usually impossible to gain Forcible language may hold them for a patients note short time. The surroundings are not correctly comprehended. or addressing a multitude. series of words and sound associations. driving a flock of sheep. The perception. and the acuity of sight and hearing being intact. The This only those objects which especially attract them.DELIRIUM TREMENS 119 The various of hallucinations may enter into the picture an occupation delirium.

of the year usually they over-estimate . Profound clouding of consciousness is found only in severe cases. They experience difficulty in collecting their thoughts. wait- ing outside the door they answer the imaginary voices. though occasionally a patient continues at his occupation until the disease is well established. escape from the get window to away from the sulphur vapors and the enemies . . The patients recall correctly where they live and facts concerning their families and occupation. The surroundings are mistaken for the bar-room.120 FORMS OF MENTAL DISEASE surroundings are confused and contradictory. is marked falsifications of memory. But the memory for recent events time of their very defective. patients show a During a conversation off into trifling incidents lead the train of thought various directions. the church for the prison. and fail in trying to solve problems which require thought. yet the distractibility. month. depending upon the character of the hallucinations or illusions. the duration of their illness. and sometimes. crawl under the bed to elude persecutors. In emotional attitude the patients are anxious and fearful or happy and cheerful. They may change rapidly from intense fear to jolly laughter. In actions they are more or less restless and talkative. They are seldom able to engage in work. are unable to recognize contradictions. also. especially for the Occasionally they present occurrence. and the length of time they may have resided in different places. and strangers are greeted as old friends. They plug the ears to keep out disagreeable noises. and even indulge in witty remarks. The train of thought is coherent. They have a wrong conception of the time of week. The memory for remote events is well retained. Usually they take an active part in their numerous hallucinations.

. of short duration. When in fear they often commit tive assaults. Some of these cases come under the care of the family physician. disturbances Physically. and in the severest cases. and sometimes of the extremities and eyelids. a number of rats scampering across the floor. with malposition of words and syllables. or amuse themselves with their beautiful surroundings and join in the happy company of imaginary revellers. symptoms stage of delirium tremens. Speech is often ataxic and paraphasic. as if some one were constant!}behind the patients. but the majority of them go without medical attendance. The physIt is ical signs of delirium tremens are usually present. The patients are per- fectly conscious. Many lance is chronic alcoholics develop what 1 in their own par- is called a " touch of the horrors.DELIRIUM TREMENS 121 run to the station for protection. Mental Diseases. and pronounced tremor of the tongue and fingers. there develops some parsesthesia. a vague feeling of apprehension. One patient saw for a cinations of sight and hearing. and appreciate their condition. It very freothers were attracted by unnatural voices. may be slurring and unin1 Berkley. rarely lasting over a few hours or days. besides the various sensory which may form the basis for illusions and hallucinations. quently happens at night that some object appears at the moment window for a second and is gone." which in reality an abortive form of delirium tremens. Sometimes they are asser- and aggressive. There is ataxia there is often great muscular weakness. the slightest noise causing them to While in this state they have single hallube startled. The are those of the prodromal During a debauch or following abstinence or mental shock. demanding attention or carrying out divine commands.

the physical With though sometimes they disthe improvement of sleep of the events of the psychosis symptoms disappear gradually. rarely reaching one hundred degrees. appear within a night. A few cases suffer relapses after a few days of clear consciousness have intervened. In a large percentage of cases the urine contains albumen and casts. because of the small amount of nourishment ingested^ which is due in part to the delusions of poisoning. spasms are noticed. rarely extending beyond three weeks. Epileptiform seizures may appearing shortly before the attack. . Course. nothing may be recalled.122 telligible. The condition of nutrition suffers. The memory depends upon the severity In the severe cases of the disturbance of consciousness. Insomnia is and persists unless the patients marked from the become stuporous. There first is apt to be a slight rise of temperature during the pulse rate ally there few days. — The duration away of the delirium varies from a few days to two weeks. Esholz finds in the blood a relative leucocytosis. The improvement comes with sleep. show the rapid clearing up of symptoms with the improvement of sleep. and occasionis profuse perspiration. and in part to the gastritis. Others show a complete alteration in the all cases Not character of the psychosis after the hallucinations and . . The hallucinations usually fade slowly. reflexes are exaggerated. FORMS OF MENTAL DISEASE Occasionally in the severe cases muscular occur. with a diminution of the eosinophiles at the height of the psychosis. first. The is low as well as the respiration. sometimes accomThe tendon panied by transitory paralytic symptoms. which clears up with the psychosis albumoses are rarely found nucleo-albumens are often present.

Here the patients. the active hallucinations. that they are worked upon by well retained. the disturbance of consciousness. while at others they are ing. The memory is dences of mental weakness are noticed in lack of judg- ment and mental apathy. irritable. or into the alcoholic delu- sional form. evidences of failure is differentiated previous history of of memory and . Diagnosis. hearing. mood. still continue somewhat reserved and suspicious. after the hallucinations. and the muscular tremor of delirium tremens. remain. have disappeared. but at the same time easily marked characteristic is the variaexcited to anger. At times they are amiable and indusat the same time recognizing that they are not well.DELIRIUM TREMENS illusions 123 have disappeared. the alcoholic. Likewise changeable delusions may persist. especially of Occasionally a few hallucinations. A tion in the trious. showing some weakness of will power. Occasionally expansive delusions are expressed for a short time. threaten- and express hallucinations. confused delusions of a religious character stand in contrast to the moderate restlessness without impulsiveness. some going over into the char- acteristic polyneuritis psychosis. if — The diagnosis is of the disease is not difficult the previous history known. patients present a mixture of anxiety In emotional attitude the aud humor. A certain number of cases pass into a condition of mental deterioration. They are ordinarily good-humored and tractable. and especially in the epileptic condition. Fever delirium and the dreamy-like conditions of epilepsy may be confused with In the former there is a more marked clouding of consciousness. and restlessness. but evi- electricity. as. complaining. The delirium of dementia paralytica from the alcoholic delirium by the change of character.

the — It is of prime importance to first establish proper nutrition. of speech Treatment. feeding by tube should be resorted to. strong coffee. or is strychnin should be substituted. physical signs. is a lack of progressive systematization of the delulittle which have but is bearing upon their actions. In the unfavorable cases (three to five per cent. The condition of gastritis may demand lavage with . hypodermic injections three-fourths . The conmental weakness following a few cases of delirium tremens may be mistaken for paranoia.). grain of aqueous extract of opium may be employed is but here also its use must be avoided where there cardiac weakness. with a ditions of there sions. advisable. sulphonal. movements uncertain and weak. Krafft-Ebing recommends repeated injections of methylal. one and one-half grains every two or three hours is procured successfully many question its use. The alcohol can be safely withdrawn at once. but in them of consciousness. sleep is Chloral in repeated doses until employed by some.124 FORMS OF MENTAL DISEASE judgment. saline solutions. except to heart weakness. and furthermore. where there is a tendency when either camphor. With the . Small quantities of liquid nourishment. and the content entirely incoherent. the symptoms of mental their paralysis appear. until sleep is procured. Insomnia and restlessness must be combated by the administration of paraldehyde. and the more profound clouding change of personality. or trional. frequently repeated must be given from the onset if necessary in order to accomplish this. this drug must never be suddenly withdrawn. Where there are severe complicaof tions or fever. the patients becoming unconscious. and this procedure. furthermore there a partial insight. The prognosis is usually favorable. but very especially where there is any cardiac trouble.

XV. During severe illness in chronic alcoholism. XXXI. . Neur. 570. f. bei Delirium Tre- Archiv f. Zeitschr. Constant watching is absolutely necessary to prevent the patient from leaving the bed and injuring himself or others. Jacobson. Arcbiv f. 229. Psy.. Psy. Psy. I. Pathologische Anatomische Befunde mens. 3. Psy. S. BIBLIOGRAPHY Liepmann. u. Jahrbucher f. Monatschr. Trommer. one should always guard delirium by maintaining against the occurrence of the nourishment and securing sleep. Elsholz.DELIEIUM TREMENS 125 taking of nourishment and the appearance of sleep. f. Psy. XXVIII. Bd. Allg. 221. LIV. 700. the condition improves rather rapidly. 2 u. Bonhoeffer.

dizziness. — The same etiological factors apply to this alcoholic psychosis as to delirium tremens. ringing bells. headache. and of guns. liars. a few prodromal symp- toms. crying. call Later the sounds become more definite. 126 have been drowned. a fellow-workman. that the children is are laughed at because of their anxiety. as. or a well-known policeman. and occasionally are heard with only one ear. usually in reference to them- These remarks appear to come from the next room. the of their own names or separate curse words. hear that they are to be electrocuted. have betrayed their native country. insomnia.ALCOHOLIC DELUSIONAL INSANITY This psychosis is characterized by the sudden development of coherent delusions of persecution. The firing patients at are disturbed only at night by indefinite noises. — irritability. or from workmen close by. They as those of the immediate family. and present before the acute onset. that the wife unfaithful. are first is yet unknown. thieves. sentences. they are called murderers. Why one case should develop into delirium tremens and another into alcoholic delusional insanity Symptomatology. or have shot the President. Occasionally. based upon hallucinations of hearing ivith retention of clear consciousness. They may be indistinct or clear. shouting voices. They Sometimes all . Very often the voices are recognized as those of a chum. Etiology. such as indisposition. but rarely ally imprecations The remarks are usuand references to misdeeds of their past life. and finally definite selves.

detectives in citizen's clothes They are distrustful of follow them wherever they go. refusing to leave their home. The to speak to them because they are implicated in the seduc- tion of their wives. but may realize that they are different. exciting suspicion. their speech coherent. of hearing. They rarely possess clear insight. patients . others creeping on the wall brilliant specks come across the At times field of vision and they may even see double. regarded as a hangman. is own indictment for murder or of these hallucinations it The content always of a depreciatory nature. questions or associate with Sometimes they refuse to answer any one imtil brought to the court room for the supposed trial. ented. and frequently accuse their persecutors of drugging . and they are able to make an accurate statement of their symptoms. seem to be the centre of attraction every one about them watches and threatens them. and to all they are unwilling listeners. Besides these numerous hallucinations few hallucinations of sight. patients are ori- The consciousness is unclouded. constantly on the alert for impending arrest. At times they compelled to listen to their their death sentence. and show considerable emotion. or they go into hiding. there are a . Strange and threatening forms appear before them. some crawling from under the bed. Their every thought and action is known and commented upon. Neighbors shoot Passers on the street jeer at them. through the fence at them. their surroundings. and his entrance into the room is Fellow-patients refuse resisted to their utmost strength. These patients argue that they are condemned to The night nurse is die. the food has a peculiar taste. At times they The find consolation in prayer and is in reading the Bible. especially at night.ALCOHOLIC DELUSIONAL INSANITY of this is 127 are heard through a telephone.

there is a mixture of anxiety and cheerfulness when they relate their frightful experiences with indifference. the duration varies from two the to three weeks. course of the psychosis may be either acute or subacute. and especially later in the course of the disease. Hallucinations other than those of hearing. When not constantly in fear. — The often present. and in replying to questions are Their actions are well directed. It is not employment for several days after the outset of the psychosis. and they monosyllabic. Many apply for avoiding attention. indicate a prolonged course. without clouding of consciousness. they are quiet. symptoms may persist from one to eight months. but at times. reserved. Physically. them or making " nervous. At the onset they are anxious and fearful. The diagnosis history." Others claim that they are The emotional attitude is usually depressed. Cases . sometimes during a night. with rapid disappearance of the sympIn the subacute form toms.128 FOKMS OF MENTAL DISEASE them crazy. tions of upon the alcoholic the acute onset. protection at the police station. When acute. are often able to help in rare for them to continue at their ward or home duties. sive. and the appearance of expansive delusions. The reflexes are occasionally exaggerated is and tremor of the tongue and hands Course. The and there is a loss of weight. upon which are based coherent delusions of the disease depends of persecution. sleep tions is regularly disturbed by hallucinaappetite fails and anxiety. A cigar They are apt to be seclumaker abandoned his for fear of detec- position tives and kept to his room many days who were after him. disappearing gradually. or perhaps laugh at the absurdity of their attracting so much attention. with numerous remissions. and the prominence of hallucinahearing.

of and the great predominance mannerisms. Added to this. which are persistently adhered to and expanded with poor attempts at systematization. seen in the mixture of anxiety and cheerfulness. is the nucleus about which deluThe patients believe that the reasions of jealousy form. constrained of hallucinations hearing without disturbance of consciousness. Paris. independently of ideas of persecution. 129 and dementia paralytica may present but are differentiated by the more sudden onset of the alcoholic psychosis.ALCOHOLIC DELUSIONAL INSANITY of dementia prcecox similarities. the lack of uniformity in the emotional attitude. and persecutory ideas. following the content of the delusions and the clouding of consciousness. only a few cases failing to recover. The estrangement naturally arising between man and wife as the result of chronic indulgence in alcohol and its necessary consequences. These. These present the picture of a light grade of deterioration. similar to that following some cases of delirium tremens a few maintain expansive . would indicate dementia praecox. or of the husband for other women. 1 Iscovescu 1 Iscovescu. The method of treatment delirium tremens. Prognosis. . 1898. is similar to that indicated in Alcoholic Pabanoia A few cases of chronic alcoholism gradually develop delusions of jealousy (Eifersucliwahn). definite changes in the emotional attitude from depression to cheerfulness. of The presence postures. Krafft-Ebing lays considerable stress upon the failing sexual powers of the alcoholic. — The outcome is usually favorable. son for this change of affection lies in the fondness of the wife for other men.

or an odd taste in the food. the arrival of an unusual letter. the ity : fondness of a friend for their children. or the coachman if he happens The reasoning in these to be amiss in any of his duties. ciated with these Asso- delusions of infidelity there may be delusions of poisoning. coherently. a creak of the door or low talking. peculiar noises are heard about the house. and even association with another man's wife. in this way they frequently convince chance acquaintances of the great injustice done. if he refuses to ers. and from noises which they side glance A have heard are sure that she was guilty of infidelity. state them tion. clanging of a car bell means that the spondent. delusions is very weak. Occasionally. This incites them to nail down the win- dows and to fasten the door in order to keep out intrudThe saloon keeper is implicated. the home and chilsuspected misbehavior. and full of absurdities. The patients. Their delusions are not built out. which he explains by the fact that women are more emotional. the voluntary imThe frequent plication of a neighbor in a family strife. but remain confined within narrow limits. dren are neglected. They have seen the wife enter the apartments of a neighbor. which leads them to believe that an effort is being made by the wife to poison them. are held as sufficient proof of the Furthermore. give them credit for liquor. and oftentimes display considerable emo- and indeed. motorman is a core- from a passer on the street. There may be a peculiar odor in the house. . however. Insignificant occur- rences are regarded as important evidence of this infidelthe assistance of some one in carrying a bundle. illogical.130 FORMS OF MENTAL DISEASE found the delusions of jealousy three times more prevalent in females than in males. which are supposed to be made by the lover.

is The course of the disease usually progressive. entiated from paranoia by the lack of system in the delusions and by the symptoms alcohol. One patient in despair drowned himself. . and this is especially true in cases of long duralive peaceably A man may with his wife whom he accuses of committing adultery night after night in his presence. they bemoan their misfortunes while submitting to the injustice. and are able to live very comfortably. The apparent improvement leads to the belief that they are suitable for release. indeed. At times the actions are entirely out of accord with their delusions. and be both aggressive and destructive. teristic with the characdelusions of persecuand alcoholic hallucinations It is of gradual onset. In actions the patients usually exhibit marked weakness. with the opportunity to secure alcohol. in fits of anger may Sometimes they are very irritable. of chronic alcoholism. soon leads to recurrence of delusions. delusions When removed from home they are not annoyed as much by their delusions. though abstinence from alcohol often produces improvement. especially in conjunction with confinement in an institution. but the return to home surThis psychosis is differ- roundings.ALCOHOLIC DELUSIONAL INSANITY There is 131 no clouding of consciousness. Alcoholic Pseudoparesis There may develop in chronic alcoholism a condition very similar to dementia paralytica. Only rarely do they take means to chastise the wife or assault the supposed lover. Tbe seldom disappear permanently. the similarity is so pronounced that the diagnosis may remain in doubt for a long time. is The from treatment of these cases limited to abstinence institution to prevent and confinement in an aggressive attacks and suicide. tion.

In alcoholics the delusions are of fear. showing contentment and indifference. hallucinations. coherent. while in paresis. persecuinfidelity. symptoms remain at a standstill. logical. leaving the patient condition of mild dementia. A few patients recover so as to return to their The which diagnosis depends in in homes and business. great part upon the course. is more marked than and the tremor more general. The difficulty the is of speech in the alcoholic due to tremor. expansive delusions. there are the disturb- ances of speech. The woes more philosophically. ataxia. with perhaps a few expansive or depressive delusions of a paranoid type.132 tion FORMS OF MENTAL DISEASE and infidelity. together with the characteristic failure of memory and judgment. but not progresin the course in a The more marked symptoms disappear of a few months. similar delusions exist they are and more easily diverted. except for the absence of the granulations of the ventricles. less and marked emotional display. course of the disease is protracted. real muscular weakness in paresis. The sive. sensory disturbances. paretic regards his in the course of chronic alcoholism. . based upon one of his own cases dementia paralytica. and mental stupidity of the paretic. and does not Also headache. and anaesthesia are more marked with more or if holism. It must be borne in mind that typical dementia paralytica sometimes develops less sustained. muscular tremor. The pathological similar to those of findings in alcoholic paresis are. is dementia paralytica paresis progressive. while in alcoholic Furthermore. in alco- include elision and omission of syllables. ac- cording to Krafft-Ebing. or even years. Physically. occasional epileptiform attacks. and exaggeration or loss of tendon reflexes. tion.

Ueber Alkoholische Pseudo-Paralyse. Zeitschr. Allg. 595. .ALCOHOLIC DELUSIONAL INSANITY BIBLIOGRAPHY Wachsmuth. Psy.. Paralysenaehnliche Intoxication Psychosis. f. 133 Marburg. 52. Llewe. Bd. 1897. S.

accounts in part for the extensive use of this drug. as hysteria. In animals to which morphin had been administered for a prolonged period. of the patients are those ill Considerably over one-half are best acquainted with its effects — is who physicians. Individuals free from this hereditary taint usually succumb to the drug after its continued employment in persistent painful affections. rheumatism. On tbe Conis tinent claimed that seventy-five per cent. are men. The pleasurable continuance. dentists. as neuralgia. together with the freedom of the physicians in dis- pensing analgesics. Pathological Anatomy. evidences of which in very many cases are manifested by various neuroses. feeling and the mental stimulus which effects are supplement the analgesic here the cause of its The majority of cases develop between the ages of twenty-five to forty years. dysmenorrhcea. and different forms of colic.MORPHINISM The extensive use and abuse of morphin for it its allur- ing effects place only second to alcohol in the production of mental and physical wrecks. — The intolerance of pain with people of this age. sciatica. its victims are limited to the better classes. Being an expensive drug. Nissl has — demonstrated a shrinkage of cortical neurones with an increase of the neuroglia. 134 . Etiology. these patients are men. the defective consti- An earlier important etiological factor tutional basis. headache. At least one-half of it and professional nurses.

Then ensues a quiet. and soon tate increased dosage. which aid in endurance of annoyance incident to his effects of this work or his home life. and its powers of resistance. also be increased. fails to produce these owing to idiosyncrasies. — The is physiological action of morphia to first produce an and excitation of the process of comprehenand a psychomotor retardation. The character of the symptoms and the time of their appearance depend mostly upon the individual constituthirty to fifty grains daily. MORPHINISM Symptomatology. of — In the prolonged use morphin the effects of acute intoxication disappear. and sometimes rumbling in the bowels. The beneficial necessi- drug diminish with usage. For him it also produces a necessary stimulus for mental work. which later passes into a dreamy state. which acts as one of the strongest enticements for the habitue. pleasurable feeling. and diminution in of the secretions of the body. profuse perspiration. which cannot be accomplished by the exercise of the will power alone. Some continue addicted to morphin throughout life without pronounced ill effect tion . Following the intoxication there is apt to all be headache. general feeling of discomfort. There usually develops a metallic taste in the mouth. reach from The frequency of the doses which soon compels the physician must to intrust the administration of the drug to the patient. in time.. which may. nausea. and colpleasurable effects for icky pains. and the individual obtains only the exhilarating and the quieting effects. Many after its exhibition suffer from a disagreeable fulness in the head. Chronic Morphin Intoxication. with changing fantastic hallucinations and an intense weariness in the psychomotor functions. Fortunately the drug all. acceleration sion 135 — Acute Morphin Intoxication.

patients are either in a condition of exhilaration or stupidity or nervous irritability. trifles. ally present. and active and restless at night. over . the memory weakens. and the bladder. and sometimes ataxic. The patients awake for hours. and they fall into a state of apathy and indolence. and other drug habits. the intestines. the sleep lie is much disturbed. Disturbances of sensibility are usu- such as paraesthesias and Iryperaesthesias. especially about the heart. with an ab- sence of will power and energy. In actions they are apt to be sleepy during the day. sometimes accompanied minds busied with all sorts of by genuine hal- lucinations of sight. especially at night. Finally all idea of personal responsibil- The home and the business suffer alike. hypochon- sometimes confidential. . these patients exhibit many variations: they are sometimes driacal . busying themselves about foolish and talking incessantly. reading. Emotionally. is Morally. They willingly submit to all sorts of depraved means in order to secure the drug. ity vanishes. There is usually an increase of the tendon reflexes. cross. Physically. faultfinding. nice. none of which are compatible with mental work. with pronounced affectation and occasionally anxious. there a pronounced change of character. able. irritable. and exhausting work becomes Consequently the impossible without administration. They are also disagreeand obstinate to the extreme.136 FORMS OF MENTAL DISEASE In these others succumb in the course of a few months. their fantastic ideas. They are careless about the dress and the personal appearance. The movements are uncertain. and Difficult its the capacity for mental appli- cation diminishes. Very many of them become addicted to alcohol. dejected. tremulous. notice- able especially in reference to their irresistible habit.

due in part to the absence of normal secretions. as well as the profuse perspiration and shivering. The appetite. according to toms called abstinence symptoms. are attributable to vasomotor disturbances. general nutrition suffers. and slow. though sometimes there is a ravenous appetite. or at most a few Occasionally there appears a condition of dazedness. are due to the action of oxydimorphin. The lack of sexual desires and impotence are prominent symptoms in women there is amenorrhcea and sterility. and there is loss of weight. The administration this of hypnotics. especially chloral. or less disturbance. especially for meat. pulse. the picture of premature senility. and are sleepless. Dryness of the mouth creates unusual is thirst. This condition lasts but a few hours. and syncope. The ringing in the ears. a condition very similar to delirium tremens may appear. The ensemble of these symptoms creates . however. is always attended with become tremulous more and uneasy.MOEPHINISM Occasionally there is 137 difficulty in speech. time. with hallucinations and convulsive movements. Marme. at only increases the excitement and aids in a delirious condition with hallucinations about bringing and dreamy confusion. numbness. Physically days. The patients . however. experience a tickling sensation in the nose and begin to sneeze feel oppressed. skin is The The flabby and dry. also paresis of eye muscles (double vision and defective accommodation). In the cir- culatory system there irregular vertigo. complain of paraesthesias of different parts of the body. Abstinence Symptoms. fails. . — The abrupt withdrawal of mor- phin in individuals who are addicted to large doses produces in the course of a few hours a characteristic train of sympThese. The with- drawal in milder cases. In spite of precaution. noticed palpitation.

and general muscular weakness. In the course of a few days. myosis. amounting in some cases almost to paresis. except excessive. in others The duration also varies some die within several years. and furthermore by the physical signs the loss of sexual : power. Course. dejection. — The rapidity with . paleness and flushing. palpitation of the heart. — The disease . while others live for doses. and irritability. spasm of the diaphragm. which during the ingestion of morphin has been diminished. anorexia. The secretion of saliva and perspiration. and the size of the habitual dose. the patients begin to sleep and develop an appetite. which the symptoms of chronic morphinism develop varies with the power of resistance of the individual and the quantity of morphin ingested in some cases it requires a few months. vomiting. Scars from the hypodermic injections should always be looked for. tenesmus. or in collapse. . The surest means of diagnosis is seclusion or close surveil- . fainting and col- sometimes fatal. a year of inanition. stupidity. and there is colliquative diarrhoea. which is Albumen The duration and intensity of the symptoms depend upon the constitution of the patient. may be recognized by the vary- ing emotional attitude periods of mental freshness and unusual energy with a feeling of well-being. many years in spite of large and increasing Diagnosis. twitchings of the limbs. where they may vanish rapidly after a prolonged sleep. alternating with great weariness. paresis of the muscles of accommodation. heart failure. is usually present in the urine.138 FORMS OF MENTAL DISEASE the patients display involuntary movements. but from this point convalescence progresses very slowly. in the lighter cases. The symptoms disappear gradually. perhaps weeks. the duration of the habit. now becomes lapse with heart failure.

the latter of which requires the greatest skill and is by far the most efficacious. The drug may be withdrawn with the proper precautions and the — . and chloral. chloroform. however. Even in these the the In cases where the abstinence symptoms may appear. also during pregnancy. Often. The treatment is preeminently unsuccessful in those with strong neuropathic tendencies. cannot be safely undertaken in cases. A few cases die from over-doses of the drug. of physical and especially where conditions the gradual and the rapid. will appear. and is apt to create chronic and disagreeable traits which in the end For these are as difficult to eradicate as the habit itself. they revert to substitutes. and after twenty-four hours to a nominal dose of one grain daily for several days. Treatment. The former involves much time and patience. immediately reduced quantity is the large. of which the most important are cocain. chronic diseases. reasons only the rapid method is outlined here. In mild cases be withdrawn abruptly. Prognosis. weakness are present. This method all of treatment. during which time the 139 demand for the drug or some abstinence symptoms. For this purpose the site is isolation in a reputable institution. which may lead to sudden collapse and fatal termination. acute and severe There are two methods of withdrawal. when the patients do not relapse into morphinism. ether. been dose has drug may one-half. is — The only successful method of treatment first requi- complete abstinence. alcohol. patients suffer no ill-effects. It is nec- essary that the patients be placed in bed. Less than ten per cent.MORPHINISM lance for a week. The prognosis is always very serious. recover permanently relapses are the rule. and in the course of two weeks entirely withdrawn. The greater danger lies in cardiac weakness. During the period of with- .

fort of the patient. faradization of the skin. the drug should at once be changed to administration by Abstinence symptoms occur within the first mouth. injections of ether camphor. the administration of hot coffee or hypodermic injections of strophanthus and strychnia are indicated. to and physical health so that they are able to return to their old associations without fear of relapse. demand careful watching on the part of the To guard against these and to add to the combe given. is con- traindicated by pregnancy or an acute or serious or chronic Diarrhoea demands no special attention. Purgation should be applied early disease. it however. best given in single daily doses in the If previously taken hypodermically. be tried. alcohol in small doses tious diet may Where there with light nutriis impending or collapse. requires many months. thirty-six to forty-eight hours after the withdrawal of the drug and physician. relief in If these fail. and reestablish the former mental in some cases a year. The greatest restlessness and insomnia If often yield to the influence of ice packs on the head. may also be relieved by the application . the last of which is often essential. one always finds immediate of return to the usual dose morphin. it is Even after being fully reestablished in necessary from time to time that the patients if be subjected to close surveillance to ascertain return to the old habit. there is a .140 FORMS OF MENTAL DISEASE is drawal the drug early evening. unsuccessful. Finally. the various hypnotics local pains may this. health. The of ice.

— The conditions giving rise to cocainism are similar to those encountered in morphinism. it is difficult For this to draw a pure clinical picture of the Etiology. is characterized by the great rapidity with which it produces profound mental enfeeblement and physical inanition. 141 . because of the frequency of its complication with alcoholism and morphinism.COCAINISM Cocain. but at the present time insufflation. It is of rare occurrence to encounter alone symptoms reason disease. of cocainism. increase of Its effects in of warmth and fall and a psychomotor intoxication : of blood pressure. although it may be taken by latter habit. Symptomatology. Large doses lead to delirious states with a drowsiness. — Cocain pulse in small doses produces moderate mental excitement. and many of them have previously been addicted stitution of cocain for to morphin. active. istration is by the syringe. Early in the history of cocainism the habit arose from the sub- morphin in the treatment of the most of the patients The usual method of adminare physicians or druggists. in distinction from alcohol and morphin in its effects. the field are similar to those of acute alcoholic paralysis. an excitement followed by The and is patient is This condition is sooner or later followed by talkative. — Acute Cocain Intoxication. feels impelled to write. Most of the patients have a strong neuropathic basis. a feeling rate. with well-being. energetic.

for but react normally. complete incapacity for mental work. sleepy and tired. Chronic Cocain Intoxication. The pupils are of nutritious food. but their activity planless they are talkative and very productive. lack of will-power. patients are over-energetic. there with a flight of ideas. the normal expression changes. found in experiments is . is The . They neglect They are very apt at times to mistrust At the same time they exhibit more their surroundings. some staining of the achromatic substance. noted sometimes in the muscular twitchings. This due in part to the fact that the drug supplies the place which they have lost all desire. a a very slight alteration in the cortical neurones moderate disintegration of the chromophilic granules. the most prominent symptom is the profound disturbance of nutrition the patients lose weight very rapidly. lengthy meaningless ticable schemes. the skin becomes flaccid is and pale. and evolving on paper impractheir professional and home duties. also their personal appearance. In emotional attitude there is a variation between exhilaration with a pronounced feeling of well-being and great irritability and anxiety.142 FORMS OF MENTAL DISEASE Nissl has tendency to collapse. writing letters. Physically. and there is tremor of the tongue. . The memory becomes defective and the judgment much impaired. and defective memory. In the circulatory system there is slowness of dilated. and a moderate increase of the glia cells. There is muscular weakness and increased myotatic irritability. and in part to the excessive glandular action which makes a continuous drain upon the body tissues. state of nervous excitement — In is one accustomed to a continous mental the prolonged use of the drug. they look . upon rabbits that in the acute intoxication there but i.e. or less indifference as to the legal consequence of their acts.

Wives are accused of illicit relations with men. diminishes. being thrust with needles. an evidence of multiple disseminated Peculiar sensations in the skin create the belief that they are being worked upon by electricity. infi- A characteristic symptom is delusions of These are frequently obscene in character. — patients act hear threatening voices compelling them to strangely. moving about on a flies. are due to the action of some The hallucinations of hearing make them suspipoison. cious of their surroundings. Their thoughts are being read . of receiving many delity. Upon the basis of chronic cocainism there may develop a definite psychosis which bears close resemblance to the alcoholic delusional insanity. with large and small objects. they believe. but most characteristic is the sensation that foreign objects are under the skin. and a tendency to faintness. mosquitoes. especially of the ends of The muscular twitchings. is accord- ing to Erlenmeyer. by means of some secret contrivance ceiling. palpitation. and which are teristic of filled see moving pictures on the wall. they are being spied patients through holes in the Some become so thoroughly frightened that they attempt to posed persecutors. or that poisonous material is being thrown upon them . and other tiny objects. which are mistaken for This.COCAINISM the pulse. the fingers and the palms of the hands. and interrupted by hallucinations. there appear suddenly hallucinations of different senses the of irritability . or in despair kill their sup- may commit the silly suicide. Cocain Delusional Insanity. spite of 143 In increased sexual excitement. scotoma. the sexual power occasionally The sleep is disturbed. . Charac- the hallucinations are the minute black specks light surface. Following a few days with anxiety and some restlessness.

excitable. and sometimes passionate. of stealthily leaving the house the family for immoral purposes. The symptoms rapidly under the influence of single doses of cocain. tation. the greater severity of the symptoms. though some may appear quite orderly. and by the fact that the delusions of jealousy appear earlier and as an acute symptom. or immediately following fresh injections of In emotional attitude patients are always the drug. Cocain delusional insanity is differentiated from alcoholic delusional insanity by its more rapid development. or of In reaction to these ideas they are as public characters. In actions they are usually very restless and unstable. There is good orienclear. while the delusions may remain for weeks or even months. while in alcoholism it has little or no effect. the sensation of objects under the skin is characteristic only of cocainism. Occasionally they are reserved and reticent concerning their delusions. . dejected. sometimes within a few days. Finally. In the markedly delirious conditions which sometimes appear there is always great restlessness. except in rare instances where the excitement is very great. usually vindictive and may The consciousness remains even become aggressive. The effect of a single dose of cocain during the psychosis produces an exacerbation of the symptoms. same indi- which is of common occurrence. The coexistence of morphinism and cocainism in the vidual. The delirious state soon disappears after the complete with- drawal of the drug.144 FOEMS OF MENTAL DISEASE and neglecting becoming known love letters. a combination of the symptoms. Cocain delusional insanity develops rapidly and its full may run increase course within a few weeks. irritable. unless in connection with cocainism. frequently leads to Morphinism alone seldom produces a rapid development of pronounced mental disturbance.

VII. klin. Berlin. sulphonal. Prolonged treat- ment with the employment of every possible means to fortify him against relapses is an important factor. Heymann. a feeling of pressure in the chest with difficulty in breathing. XXIV. 483. and also by a nutritious diet. etc. Annales Medieo-Psychologiques. resist temptation for any of treatment Treatment. 1886. 19. Ueber Cocainsucht. "Wochenschr. as alcohol. Berlin. Thomsen. Wochenschr. 439. The symptoms of intoxication clear up after is the withdrawal of the drug.COCAINISM 145 The prognosis in cocainism is unfavorable for complete recovery. Chariteannalen. coexist. 278. The insomnia may camphor. where it can be determined with certainty that the patient does not have access to the drug. which requires patience on the part of the patient and perseverance and tact on the part of the physician. 1888. arises. coffee. and few great length of time. drawal. S. strychnia. . be combated with prolonged warm baths. klin. Saury. and occasionally by a tendency to If such emergency faintness which simulates collapse. and insomnia. similar to that employed in morphinism.. 1887. XII. Wien. Obersteiner. Deutsche Med. 405. such as uneasiness. successful method The rapid method of the withis best. ment in successful treatment is confinement in an institution. cocain should be withdrawn BIBLIOGRAPHY Erlenmeyer. An essential eletrional. The withdrawal usually attended only by unimportant symptoms. S. but the power of resistance profoundly affected. also palpitation of the heart. it is necessary to employ stimulants. Zeitschr. 1889. If morphin- ism and cocainism first. is — The only is complete abstinence.

dressing. of glandular activity in the thyroid supposed to be the exciting cause by failing to neutralize or care for some toxic product of metabolism. with increasing difficulty of apprehension. is — The onset gradual.THYROIGENOUS PSYCHOSES from disturbance of the thyroid gland are myxcedematous insanity and cretinThey develop directly as the result of an absence of ism. The patients do not well as formerly. in all cases The gland This is fre- found atrophied or diseased. The increasing difficulty in applying the mind and in performing even simplest acts finally renders them completely helpless. It takes comprehend written and are unable to or spoken language as collect their thoughts. Mental Disturbance op Myxcedema The mental disturbance characteristic physical characteristic of myxcedema is that of a simple mental deterioration accompanied by the Etiology. is — The lack is symptoms of the disease. cretinism appearing in early childhood. sometimes of colloid degeneration. Symptomatology. Memory for recent events becomes defective. them longer to perform ordinary duties. quently the result of connective tissue increase. and rarely of tuberculosis or of the mental disturbance syphilis of the gland. of psychosis arising The two forms glandular activity. and myxcedematous insanity in adolescence and later. There is no clouding of consciousness. At first they exhibit some 146 . such as and they also tire easily.

rough. The blood changes vary . Finally the skin and mucous membrane become anaemic and very sensitive to cold menses cease. diminution. and in the abdominal wall. and a fine tremor. fainting. and very seldom give evidence of thought for themselves or their future. Sometimes they develop restlessness and moderate excitement with stubbornness. and temperature becomes subnormal. and in a few cases . The nervous symptoms consist chiefly of headache. producing thick lips.THYROGENOUS PSYCHOSES 147 insight into their defects. sometimes there is an increase of the red corpuscles. unwieldy. convulsive spells. broad nose. progresses to advanced deterioration. They rarely express pleasure or pain. In rare cases there may appear conditions of confusion with hallucinations and delusions. Occasionally there are intermissions. The voice is changed. and at times fearful. not only in reference to themselves and their condition. but also to their environment. Course. and unless appropriate treatment is applied. the disease terminating fatally through the intervention of some intercurrent disease. Physically. The mucous memand the tongue is thick and The cutaneous change is most marked in the supraclavicular region. extreme physical weakness and profound is — The psychosis of gradual onset. disturbance of nutrition. and deforming the hand and brane is similarly involved. vertigo. The skin becomes thick and dry. fingers. they present characteristic cutaneous and nervous symptoms. in the ivpper arms. inelastic. and at other times a . becoming rough and monotonous. and the speech is slow and difficult. dejected. but later this gives way to indifference and stupidity. In emotional attitude it is characteristic for them to be anxious. obliterating the characteristic lines of expression in the face.

Relapses may occur. The patients become active and show an they improve in interest in themselves and surroundings memory and in judgment. and irregular cardiac action. of unsuccessful cases is difficult to ascertain at present. Not all cases recover through medication the number ache. beginning at one and one half grains. except for some lassitude. Cretinism. guarding care- fully against intoxication symptoms. . the absence of Treatment. indicated by head- The dizziness. . . 1896. The physical symptoms improve with equal rapidity. In the most successful cases the patient appears quite well at the end of two months. one to three be regarded as a specific remedy in this The dose gradually increased.148 FORMS OF MENTAL DISEASE in spite of marked improvement occurs treatment. u. Myxoedem 1896. improvement becomes evident within a week and increases very rapidly. Buschan. Ueber Myxoedem und verwandte Zustaende. — The administration may is of dried thyroids of the sheep. disease. Die Erkrankungen der Schilddrtise. times daily. BIBLIOGRAPHY Ewald. which persists for a long time.

and are of the stunted globose form peculiar to idiocy and other forms of defective develop- Symptomatology. It is unknown whether this infectious organism is the cause of an atrophy. Etiology.. associated with loss of function of the thyroid. Sporadic cases occur as the result of congenital absence of the gland or its atrophy during or following a fever. and from an some way associated with disease of the parathyroid gland. processes. and accompanied by definite physical symptoms. — The cortical neurones are deficient in number and ment. in this way producing a failure of mental development due to the direct action of the organism Other important or its factors are defective neuropathic basis and unhygienic or whether it is toxin upon the nervous system. CRETINISM Cretinism is characterized by a more or less high-grade defective mental development. — The symptoms 149 of the disease are . in Vermont. The is disease arises in organic infectious material. The morbid anatomy is still dilatation of the ventricles of and Asymmetries doubtful. a non-development. Pathological Anatomy. or disease of these glands. In Europe the cases are most numerous in the Alps and Pyrenees in America. — . also hyperostosis of the cranium. The disease is mostly endemic in mountainous regions. surroundings. the brain and atrophy have been found. or in connection with goitre.

The nose is broad. . and the ears are prominent. of applying themselves to They are rather indifferent and phlegmatic. insanity. The hair is scanty. hanging dependent in folds. The broad face. and are slow and awkward . stupid. and the neck short and thick. the long bones fail to develop in length. presents a very characteristic picture. with heavy cheeks and eyelids. especially in the neck. the gait slow and cumbersome. with thick lips and broad short nose. At that time they appear dull.150 first FORMS OF MENTAL DISEASE noticed during the first and second years. The tongue is thick and clumsy in its movements. increases in size have not learned to walk in their movements. extreme stupidity. sleepy. life. A few cases preTheir condition remains unchanged throughout in idiocy. the skin is thickened as if padded. and in severe cases instead. The gland ishes. The sexual organs develop slowly. the patients of imbecility . The head is large. indifferent. the symptoms they are inca- pable of apprehending or of elaborating impressions. and dentition is late and the teeth poor. develop. from the sixth to twelfth year . slurring. becoming thicker. The movements are unwieldy. except as interrupted by short periods of excitement. similar to those occurring This condition may form a basis for the development of other psychoses. in three-fourths of the cases in the remaining fail to it dimin- Mentally. and stammering. The speech consists of inarticulate sounds. pre- senting about the capacity of a five-year old child. which are loud. presenting dull. coarse. and unable to care for themselves or talk. except in a few cases where the children are born goitrous. stupid. and in places. especially manic-depressive Physically. The limbs are large and pudgy. and quite incapable sent a condition of any work. Convulsions are rare.

Amer. 503. readily succumbing to intercurrent diseases. 1893. Osier. Jour. Many — observers agree that it is advisable as a prophylactic measure to send children and families with cretinoid tendencies to the high mountains.CEETINISM 151 remain entirely undeveloped. Dictionnaire encylopedique des sciences medicales. f. Sporadic Cretinism. Cristiani. II. if given early. Bircher. may aid in preventing the development of the disease. Patients have little power of resistance. but the mental . .. thickness of the skin and amenor- symptoms cannot be BIBLIOGRAPHY Bailarger et Krishaber. 1897. p. Allg. CVI. 349. Nr. Bourneville. freniatria. Med. Cretin. Vol. Potassium iodide in small doses seems to be beneficial. Zeitschr. Volkmanns Annali de klinische Vortraege. Treatment. After an of extended duration the same drug the physical symptoms rhcea. Progres medical. 1897. Psy. which may bring about a complete recovery in children who already show some signs of disease. 1879. may improve some altered. cretinisme et goitre. 776. L1V. 10 u. endemique. The hygienic surroundings must be improved with special attention to drinking water. Jentsch. 357. According to recent observation the administration of desiccated thyroid. Sci.

As the name indicates. because it enables them to include a few cases characterized by similar symptoms which appear in patients long The group of cases as past the period of pubescence. of the . besides understood by us is a large hebephrenia. a disease of early life. ever. cases appear before the twenty-fifth year. Pick. howin hebephrenia almost three-fourths of the cases appear before the twentyfifth year. especially the Italian. Pick. and includes. the catatonia of Kahlbaum and certain forms of paranoia which undergo early deterioration. in catatonia sixty-eight per cent. Some psychiatrists. to a group of cases including the hebephrenia Hecker and Kahlbaum. of which progressive menmost prominent. use the name primary dementia. Since then the meaning of the term has been extended so as to include a larger group of cases appearing in earlier life. 1 in 1891. a difference in the various forms There is.. it is More than sixty per cent. 1891. Etiology. 1 In the hebephrenic form A. characterized by a progressively chronic course with symptoms. 162 . The disease is one of the most prominent. of all certain fundamental tal deterioration is the — admissions to institutions. Prager med.DEMENTIA PRECOX Dementia precox of is the name first applied by A. characterized by maniacal symptoms followed by melancholia and rapid deterioration. Wochenschr.. compromising from fourteen to twenty per cent. one. and in the paranoid only forty per cent.

of the cases are 153 in catatonia. as appears in about seventy per cent. puerile expression. act as the exciting causes in a small percentage of cases (ten per cent. of cases. but in most cases is permanent and progressive.DEMENTIA PKjECOX sixty-four per cent. men. physical and at least have always been weak-minded. being It varies somewhat in the more prominent and in the paranoid and catatonic. especially typhoid scarlet fever. Head injuries precede a still smaller number of cases. and the frequent appearance of the disease is unknown. and least in hebephrenic forms. precocious piety. stigmata are occasionally encountered. different forms. Defective a prominent factor. Various susceptibility to alcohol.). impulsive actions and great seven per cent. judging from the clini- and especially in those cases where there has a definite disease In been rapid deterioration. and strabismus. Pathology. also to be noticed that many cases of imbecility develop a psychosis different in no essential particular from . cal course. — It seems probable. that there a few cases this is k process in the brain. Acute diseases. for the first time during pregnancy and puerperium. few cases that recover and the larger number that show a permanent mental defect. further it is assumption It is is made that the result of autointoxication. malformation of the ears and palate. the presence of disturbances of menstruation. A number of patients present mental peculiarities from youth up. such as seclusiveness. such as asymmetries. it and paranoid forms heredity is women slightly predominate. The means by which these assumed changes are brought about in the nervous system the impairment of function This pathological basis finds clinical expression in the In consideration of the close relationship with the age of puberty. involving the cortical neurones. a reparable lesion.

or in the landscape. External impressions are correctly perceived. apprehension. however. that — The disease picture appears so varied upon superficial observation the fundamental symp- toms are not recognized. to see surprising how many It is not things in the environment are perceived. and person. and especially in the apparent stupidity and indifference which it is characterize the later stages of the disease. adds weight to this belief. as well as other mental phenomena. As yet no one with the present methods of research has been able to demonstrate an anatomical pathological basis for the disease. as the disease advances and deterioration appears. may tory stupor or excitement but even in these conditions. and furthermore that epileptics and idiots at the same age show a tendency to undergo a decided mental deterioraThe total absence of any definite external cause. In the field of apprehension there is usually very little disturbance. as well as imprisonment and acute diseases. apprehension During the acute or subacute is affected. This . This the patients being able to recognize their environment and to comprehend most of what takes place about them. permit of an early recognition of the disease process and become more and more marked as the disease progresses. and there is also appear during transi- some disorientation. Symptomatology.154 FORMS OF MENTAL DISEASE dementia prsecox at the age of sexual development. onset of the disease. in the furniture. explains the fact that they remain quite well oriented. becomes perceptibly impaired. These symptoms. place. Defective heredity. Occasionally delusions entertained by the patient lead to . tion. Nevertheless. is presumed to act by lessening the power of resistance to autointoxication. except in isolated cases. unusual to find that they notice changes in the physician's apparel. as to time.

but may persist into the end stages. patients perceive objects about any given moment is an never persistent enough to In spite of the fact tbat the them correctly. or the hospital be regarded as a nunnery. fear . but in conditions of excitement and stupor there sciousness. Consciousness is usually clear. as the patients later are able to give some details of things that On the other hand. and the patients when questioned are unable to give patients much information about them. clearest The controlling force of interest lacking. Halluhallu- cinations of hearing are most prominent. Hallucinations at first are distressing. 155 They may may be days or years ahead of the correct time. there is pronounced impairment of is voluntary attention. communications are both incoherent and silly. which is one of the most fundamental altogether symptoms. while in other respects the is orientation Apprehension the disease. and at rare intervals we find those of touch. is always some clouding of con- however. superficial observation. next come cinations of sight. so that the presentation which happens to be the and most distinct at accident of passing attention. especially in acute and subacute development of These usually disappear later in the course of the disease. Some whose During exacerbations seem to take pleasure in listening to the voices. always more or less distorted by hallu- cinations. resulting in but later in the course of the disease they do not excite much interest. occasion connected activity. is fictitious names. It is. of the disease the hallucinations may induce the former fear and distress. they do not . much less marked than one happened would judge from in the interval.DEMENTIA PRECOX a misinterpretation of some of their surroundings. their nurses may be called by correct.

156

FORMS OF MENTAL DISEASE
them
closely or attempt to understand them.
it

observe

In
abso-

deep stupor and in the stage of deterioration
lutely impossible to attract the attention in

is

any way.

In

the catatonic form of dementia praecox the presence of

negativism inhibits

all active attention.

This becomes evi-

dent as the negativism gradually disappears.

The

patients

emerging from
ing about

this condition are

caught stealthily peep-

when unobserved, looking out of open doors or windows, and following the movements of the physician, but when an object is held before them for observation
they stare vacantly about or close their eyes tightly.

There is a characteristic and progressive, but not profound, impairment of memory from the onset of the disease. Memory images formed before the onset of the disease
are retained with remarkable persistence,

— retention
may
is

is

good.
difficult,

Though

their reproduction

is

increasingly

more

unusual stimulation or excitement
of deterioration,

occasion

the recollection of events long since supposed to be effaced

by the advance

recollection
is

not

free.
diffi-

The formation
cult with the

of

new memory images

increasingly

advance of the disease.

Memory

for recent

events

Events previous to the onset, especially school knowledge, may be recalled after the patients show
is

poor.

advanced deterioration. One patient had a remarkable memory for geography, having retained the population,
area,

and some of the physical
recited parrot-like.

characteristics of almost all

of the countries of the world.

Such

facts are almost al-

ways

Some few

patients keep a care-

ful account of the length of their residence in the hospital

and elsewhere. Events during stupor and excitement are not remembered at all, or at most indistinctly. In the earlier stages of the disease thought shows a characteristic incoherence and looseness. One finds even in

DEMENTIA PKjECOX

157

the mild cases some distractibility, a rapid transition from

one thought to another without an evident association, and interpolation of high-sounding phrases. In severe cases there is genuine confusion of thought with great incoherence and the production of new words. In cases
of the catatonic of stereotypy
;

form

especially,

we meet with
is

evidences

the patients cling to one idea, which they
Besides, there occasion-

repeat over and over again.
ally noticed a tendency to

rhyme

or to repeat senseless

sounds.

In judgment there appears from the onset a progressive

While patients are able to get along without difunder familiar circumstances, they fail to adapt themselves to new conditions. Owing to their inability
defect.
ficulty

to grasp the

meaning

of their surroundings, their actions

are irrational.

This condition of defective judgment be-

comes the

basis for the development of delusions.

The

patients believe that they are the objects of persecution,

and they may have delusions of reference and self-accusation. The lack of judgment becomes still more apparent
in the silliness of their delusions.

At

first

the delusions

may

be rather stable, but later they tend to change their

content frequently, adding
the environment.

new elements

suggested by
delusions

Even
first

relatively

persistent

are constantly taking on

new meanings.

Furthermore,

the delusions, which at

are of a depressive nature, later

may become
pears.

expansive and grandiose.

In most cases the

wealth of delusions so apparent at first gradually disapA few delusions may be retained with further
elaboration from time to time, but they are usually ex-

pressed only at random.
delusions,

During exacerbations the former

to the foreground.

whether depressive or expansive, may again come In the paranoid forms, however, there

158
persists

FORMS OF MENTAL DISEASE

from the beginning a great wealth of delusions, but these become more and more incoherent.

The disturbance of the emotional field is another of the There is a characteristic and fundamental symptoms. progressive, more or less high-grade, deterioration of the emotional life. The lack of interest in the surroundings
already spoken of in connection with the attention

may

be regarded as one phase of the general emotional deterioration.

Very often
is

it is

this

symptom which

first calls

attention to the approaching disease.
notice that there

Parents and friends

a change in the disposition, a laxity in

morals, a disregard for formerly cherished ideas, a lack of

toward relatives and friends, an absence of their accustomed sympathy, and above all an unnatural satisThey fail to faction with their own ideas and behavior. exhibit the usual pleasure in their employment. As the disease progresses the absence of emotion becomes more marked. The patients express neither joy nor sorrow, have neither desires nor fears, but live from one day to another quite unconcerned and apathetic, sometimes siaffection

lently gazing into the distance, at others regarding their

surroundings with a vacant stare.
fortable positions,

They

are indifferent

as to their personal appearance, submit stupidly to

uncom-

and even prodding with a needle may
Food, however, continues to attract
is

not excite a reaction.

them

until deterioration

far advanced.

Indeed,

it is

not

unusual to see these patients go through the pockets and bundles of their friends for goodies, without expressing a
sign of recognition.

This condition of stupid indifference
irritability.

may

be interrupted by short periods of

Early in the disease, and especially during an acute and
subacute development, the emotional attitude
of depression

may

be one

and anxiety.

This

may

later give

way

to

DEMENTIA PK^ECOX

159

moderate elation and happiness. The latter, however, in a few instances prevails from the onset. Yet emotional
deterioration remains a fundamental
Parallel with the

symptom.
are

emotional

disturbances

found
is

disturbances of conduct, of which the most fundamental

the progressive disappearance of voluntary activity. One of the first symptoms, of the disease may be the loss of
that activity which
is

peculiar to the patient.
sit

He may
if

neglect his duties and
of the day,

unoccupied for the greater part
persist-

though capable of doing good work
appear a tendency to impulsive

ently encouraged. there

Besides this characteristic inactivity,
acts.

may

The

patients break out

window

lights, tear their clothing into

break furniture, throw dishes on the floor, or injure fellow-patients, all of which seems These states usually done without a definite motive. pass off very quickly, though in some this tendency may be more marked for a period of a few days.
strips, leap into the water,

The

inability to control the impulses

is

also present in the

stuporous conditions, and especially in the catatonic form of dementia praecox. Here each natural impulse is seemingly met and overcome by an opposing impulse, giving rise to
actions directly opposite to the ones
condition,
desired.

In this

which

is is

called negativism, the patients resist

everything that

done for them, such as dressing and

undressing, they refuse to eat

requested, or to them, to open their mouth or move in any direction. In extreme conditions there may

when food eyes when

is

placed before

even be retention of urine and
unusual
to their
to

faeces.

This condition varies
It
is

considerably in intensity at different times.
see

not
it,

the

patients

suddenly relieved
after an

of

assume their former

activity, talking freely

and attending
interval
of

own

needs, and

again

a

160

FORMS OF MENTAL DISEASE

few hours or days relapse gradually into the negativistic
state.
Still

another condition

is

produced by the repeated

recurrence of the same impulse, giving rise to a great
variety of stereotyped movements

and

expressions.

The

verbigerations and mannerisms of the catatonic are ex-

The patients repeat for hours similar expressions, utter monotonous grunts, tread the floor in the same spot, dress, undress, and eat in a peculiar and constrained manner. While these symptoms vary considerplained in this way.

ably in individual cases,

it is

unusual not to find at least

some of them present in every case. The capacity for employment is seriously impaired. The patients may be trained to do a certain amount of
routine work, but they utterly fail

new.

when given something few patients display artistic abilities, as, for instance, in drawing or in music, but their efforts are characterized by eccentricities. They may show some

A

technical skill, but their productions exhibit the absence
of the finer aesthetic feelings.

Physical Symptoms.

— Most

prominent

is

the disturb-

ance of nutrition.
lose
in weight.

The patients suffer from anorexia, and The sleep is usually much disturbed.
is

The

heart's action

sometimes retarded, sometimes

accel-

erated,

and

often

weak and

irregular.

Occasionally

vasomotor disturbances have been noticed, such as cyanosis, dermographia, and excessive perspiration. In many cases there has been detected a diffuse enlargement of the glands. The menses almost always cease. The pupils
occasionally are dilated, and especially during conditions
of excitement

and

stupor.

The tendon
myotatic

reflexes are usually

increased as well as
these

the

irritability.

All

of

symptoms tend

to disappear later in the course of

DEMENTIA PRECOX
the disease,

161

when the patients develop a good appetite, take on weight, the menses reappear, and the skin assumes
its

normal condition. Some observers have reported fainting and epileptiform attacks in eighteen per cent, of
cases.

Hysteroid convulsions and paralyses and localized

contractures have also been noted.

HEBEPHRENIC FORM
The
few cases

(Hebephrenia)

onset of the psychosis in this
it is

form

varies.

In a
first

so insidious in origin that the relatives are

unable to place the date of the appearance of the

symptom. Usually the patients complain first of headache and insomnia, then a gradual change of disposition comes over them. They lose their accustomed activity and energy, becoming self-absorbed, shy, sullen, and secluThey sive, or perhaps irritable, obstinate, and careless. may become rude and assertive, or they may be perfectly
indifferent.

They
sit

are careless of

their

obligations, are

thoughtless and unbalanced.

They accomplish nothing,

but rather

about unemployed, apparently brooding or

to go to bed, lying there for

engaging in useless conversation, or they leave their work weeks without evident reason.
Others, instead of this inaction, exhibit a

ness,

and continuous
stroll

effort is impossible.

marked restlessThey leave their

work,

about or ride wheels from place to place,
Others, with increased sexual passion,

especially at night.

illicit and promiscuous intercourse. During this period, which may extend through several months, there are apt to be remissions, when for a short time the patients improve greatly and may even appear

indulge in

natural.

Women show premonitions of

the disease during

the menses.

More often the onset is characterized by a period of when the symptoms appear more rapidly and are more pronounced. Here the patients become more
depression,
162

DEMENTIA PRECOX
apprehensive,
dejected,
sad,

163
suspicious.

and sometimes

They
have

are troubled with thoughts of death,

life

seems to

lost its charms, and friends appear indifferent. Their mental condition at this time often leads to suicidal

attempts.

Hallucinations, especially of hearing,

and

less

often of sight, appear at this period.

The

patients are

annoyed at strange noises, unintelligible voices, unfavorable comments upon their personal appearance they hear threats and imprecations, music and singing, telephone messages, and commands from God. They may also see heavenly visions, crosses on the wall, dead relatives, frightful accidents, and deathbed scenes. Occasionally they smell various odors, especially illuminating gas and sulphur. A patient may experience various hyperaesthesias which lead him to believe that his head is double, that the throat or nose is occluded, that the genitals are being consumed, or that the bowels are all bound together. Preceding the appearance of the hallucinations, and accompanying them, there develops a tendency to the formation of delusions, which are almost always of a
;

depressive character.
guilty of

The

patients

believe

themselves

some

crime, accuse themselves of being mur-

derers, claim that they are lost, are
live,

have practised
its
ill

self-abuse,

damned, are unfit to and can never recover
their

from

effects.

They

suspect

surroundings,

detect poison in the

food, are

being worked upon by

others, their thoughts are not their own, friends have

turned against them and are trying to do them harm, some one is watching them constantly, and they are being
harassed by various agencies. Women are followed by men who would ravish them. Later in the course of the
disease,

and occasionally from the
;

onset, the delusions are

expansive

the patients regard themselves as prominent

164

FORMS OF MENTAL DISEASE
Son
of

God, the Creator, the possessor of the universe, they converse with God, are the Saviour of men, have all knowledge imparted to them or can stop all wars by lifting their hands. Some of these They fancy that patients are controlled by sexual ideas.
individuals, the President, the

they are betrothed to prominent individuals of the opposite
sex.

Men

believe themselves possessed of

many

wives, or
all

regard themselves as the centre of attraction for

women.
These delusions

may

be augmented by numerous fabrica-

tions ; the patients claiming that they

have been President

commandant in various engagements, have been knighted, that they have been in heaven, have possessed the key of hell, have just returned from a visit to Mars, where there is eternal war. These fabrications, together with delusions, gradually recede to the backfor a century, chief

ground.

At

first

they become fewer,

less fantastic,

then

and still more scanty, until finally in the advanced stages of the disease there remain only incoherent residuals, which may never be expressed except as the
incoherent,
result of questioning or

during excitement.
is

Some
first

insight into their condition
patients.

often expressed at

by the

They

are conscious that a change

has come over them, and often complain that the head
feels

strange, benumbed,

and empty.
rotting, the

These

may
is

be ex-

pressed in connection with somatic delusions, the patients

saying that the brain
confused.

is

memory

failing,

that they are different in every

way and

are very

much

Even

this scanty insight gradually disappears

as the disease progresses.

In those forms of the disease which develop
there
is

slowly

at first neither clouding of consciousness nor

marked

disturbance of orientation.

In the acute or subacute onset

trying to kill them. The physicians are regarded as enemies. than monosyllables. still believed that both the physician and himself had been entrapped in a prison and that they must hasten to escape. but it. working upon them with electricity. at first mostly for recent and passing events. The patients mistake persons. The memory from the onset presents a progressive deterioration. do not appreciate where they are. the content of speech being both coherent and relevant. are not remembered. Without them.DEMENTIA PRECOX cloudiness 165 and general disorientation may unite in the clinical picture with pronounced hallucinations and delusions. and are unable to record passing events. The association of ideas is at first very little disturbed. surrounded by saints. this there is thought. etc. A patient. such as time of admission to hospital. The memory of earlier life and the chronological order fail to elicit become disconnected anything more of events is well retained for a long time. anxiety and restlessness and incoherence of thought. Questions The ideas and incoherent. The events dating from the onset of the psychosis. to tell Some of the patients are able with surprising accuracy the exact definitions in geography and many historical events almost word for word. The patients may be able to control their attention. etc. but later in the disease with progressive deterioration thought suffers profoundly. They are confined in a prison for some grave offence. and they fail no incentive for observation and to observe what is going on about As the disease progresses. although he recognized the physician. or are among the heavenly hosts. or at best only imperfectly. as committed to memory years before. there is increasing limita- . with notable exceptions. they do not try to do There is a total lack of interest. or entirely irrelevant remarks..

they enjoy obscene literature. Whenever we do self-centred. but later because they are led by God or ordained feelings very often some special work. however. to recall events that seemed to have from them. praying frequently. This may not be so evident while the patient is confined at home. as long as his thought is employed with familiar facts and his range for action limited. He is unable to reason. reading their testaments. or to overcome obstacles. The defect in judgment appears early. write long letters to acquaintances. to perform mental work. incoherent delusions. In both sexes these feelings are apt . the patients being devout. or during the early part of his residence in an institution. It becomes apparent.166 FORMS OF MENTAL DISEASE For it is tion of thought. and becomes profound. this ences are seldom recalled. same reason their past experiand so finally fade from their memory . they masturbate course. to recogThe defect nize contradiction. peevishness. in reaction to unusual stimulation. at to do first apparently in the spirit of penitence. At sion. giving expression to their lascivious feelings. and solicit inter- The female patients are more apt to associate with their own sex. In emotional attitude the most prominent and permanent feature is that of emotional there dulness and it is indifference. when he leaves the trodden path and attempts to adapt himself to new circumstances. and often irritability. though not unusual for them. particularly in those addicted to the habit of masturbation. develops rapidly. Exaggerated expressions of religious feelings are apt to be prominent. The sexual play a prominent role. can also be seen in his tendency to formulate and hold to entirely passed senseless. tre who have been Thought may cen- about sexual matters . find emotional activity first is increasingly usually more or less depres- with anxiety.

travelling They may even run away and secrete themselves. both expansive and hypochondriacal. A young man was found throwing stones into about without evident purpose. all sorts They neglect their personal of outlandish and foolish prowling about all night. the most characteristic symptom The is that of childish silliness and senseless laughter. They express emotion at the loss of friends. trees because the voices of evil spirits annoyed him. 167 Later in the disease the delusions. at the next as supremely tractable. and finally are completely incapable of continued and comprehensive employment. setting fire to buildings. perform deeds. voluntary activity is inconsistent and lacks independence. At one moment they appearance. The patients are very often seen to converse with them- sometimes aloud. such as are increasingly headstrong. while associated with this there is almost always silly laughter. fruit. A mates to a graveyard and covered student ran from himself with leaves in order to obtain aid in committing A girl of fourteen attempted to stab her his ivy oration. and . throwing stones to break windows. at the visits of relatives. They live an unusual supply of food. believing him unfaithful. or cana very empty life.DEMENTIA PILECOX to disappear later in the course of the disease. are expressed fail to without display of emotion. In conduct and behavior. forget their obligations. or as unexpectedly demand some one in marriage. his lover. even bringing them to her home for that purpose in the presence of her husband and children. appears on all occasions without the least provocation. A young married woman solicited intercourse among gentlemen friends. or at dies. anxieties. It is unrestrained. devoid of any cares or and without thought for the future. This silly laughter is a very selves. prominent and characteristic symptom.

containing many stilted phrases. The structure changes frequently. and the emaciated condition is frequently replaced by great corpulence. and vasomotor disturbances may be present. The tendon reflexes may be exaggerated. — Dming and copious underlining.168 is FORMS OF MENTAL DISEASE Besides these altogether without emotional significance. At this time the weight often rises rapidly. both by anxiety and distressing dreams. the onset of the dis- ease the condition of general nutrition suffers. The sleep also is much disturbed. pre- stereotyped expressions and movements. The menses also reappear and remain restrained directed . There is a and some patients even become emaciated. eating and walking. by suspicion and fear. stale and obsolete words. Physical Symptoms. Their speech presents peculiarities indicative of looseness of thought and confusion of ideas. while the handwriting characterized by a is marked lack or a superfluity of punctu- ation marks. shading of letters. The pupils are occasionally dilated. or because they are so by God. The menses cease or become irregular. Their remarks may be artificial. mannerisms. which are verwitticisms. All this becomes even more apparent in their letters. bose with frequent repetitions. A few of the vail : mannerisms characteristic of the catatonic may echolalia. The incoherence of thought becomes most evident in their long drawn out sentences. foreign expressions. loss of weight. and there are many senseless interpolations. poor. in which there is total disregard for grammatical structure. actions. The skin loses its normal healthy appearance. echopraxia. The appetite is Patients eat sparingly or not at all. Later in the course of the disease the appetite returns and often becomes excessive. such as peculiarities of speech and movements. becoming dry and flaccid. are often present.

DEMENTIA PRECOX normal. sluggish. Of the cases that are admitted to insane institutions. and led to meals. anergic. External objects usually fail to make an impression upon them. — The course is of disease in this form is progres- leading to characteristic states of mental deterioration of different grades. except in a very small percentage of cases. In some cases. and great show there may be a clouding of conscious- ness with great impulsiveness. terioration. 169 irrita- Course. are incapable of caring for themselves. occasion- ally they may be seen to laugh sillily or repeat to them- some unintelligible is word or syllable. Questions are apparently . are slovenly. the deterioration ap- pears in six months . and the evidences of muscular and nervous bility disappear. silly aggressiveness. At table they and smearing themselves with evidence of voluntary activity. about seventy-five per cent. apathetic. sive. The degree of mental defect increases more especially following the transitory periods of excitement. it may not be evident few from year to for a years. increased incoherence of singing. and insubordination. year. spattering food. indolent. The course bility. have to be dressed and undressed. marked by short periods during which the patients show great motor restlessness. are unproductive and mute . Their attention attracted with difficulty and held only for a short time. thought. reach a profound degree of deThese patients are dull. irritasexual excitement. are untidy. They give but little They selves seldom speak. These states of deterioration are usually reached within two years of the onset. of emotion . where the development in other cases of the disease has been very rapid. dancing. Tbey remain seated for hours wherever placed. and fail to apprehend the surroundings.

of the cases deterioration is not as far advanced. Relacarried out. In about seventeen per cent. correctly may be however. recognized a college mate. One of my patients was the patient often surprises one. Simple These are usually monosyllabic and irrelevant. and we have nothing the unproductive vegetative organism. silly. after the degree the subsidence of the more acute symptoms. pull out their hair. in many cases for retained a long are knowledge former time. directions. who for two years had of their sovereignties. of These patients. sitting through the day with bowed head. producing an incoherent babble with are silly laughter. Dur- ing the periods of transitory excitement these patients very apt to be aggressive. They are oriented and have a certain amount of insight into their mental incapacity. but they are and present the residuals of hallu- cinations and delusions. Instead of the extreme stupidity and indolence some patients continue restless and talkative. show a cer- amount of mental activity and are capable of some employment under supervision. and frequently show homicidal tendencies. entirely unmindful of his surroundings. of the Pacific and give the names islands the able to name Another.170 FORMS OF MENTAL DISEASE seldom exciting intelligible answers. tives been mute. untidy. to masturbate shamelessly. breaking windows and attacking fellow-patients. unable to care for himself. retain but A few patients some remnants quite unbalanced. uncomprehended. and laughed at some relics of college In the course of time even such former left mental activity disappear. such as historical and geographical facts and the In this respect ability to solve problems in arithmetic. air of dignity. Bits of and acquaintances may not be recognized. of mental activity. straightened up with an jokes. but lack mental energy and the power of applicatain .

changeable and inco- herent. The are usually purposeless. but is weak and memory Impor- may be retained. Or. rarely influencing their behavior. there is a tendency for the deterioration to increase as the patients advance in age. so here.DEMENTIA PRECOX tion. and unable to advance in their Later their field of thought profession or occupation. In conduct they are apt to present many mannerisms. if pondering over abstract and useless questions. selves profitably. reaching home the patients fail to employ themupon but They spend much time in reading. are unbalanced. which are apt these to be coincident with menstruation. 171 They have little interest in the surroundings. restlessness. with a reappear- ance of former delusions and hallucinations. evolving impractical A schemes. defective. but at times there single may be verbigeration actions and repetition phrases. while they are quite incapable acquiring additional knowledge. The hallucinations and delusions of the various stages of the disease for the While retained in a few most part entirely disappear. As in the other grades of dementia. and incapacity for employment. few cases leave the institution apparently recovered. employed they show a lack of interest. cases. but are contented to live and be cared for. talkativeness. becomes more circumscribed and their relations with the . sions are more apt of to be expansive. they are of little importance to the patients. At with times the patients show motor great irritability and sometimes violence. The judgment tant events edge. and no thought for the future. cially noticeable following This of is espe- short periods excitement. together with school knowlmemory for events subsequent to the onset of is the psychosis of very poor. no care for their own livelihood. The delusilly behavior.

because in some instances there have life. way we lose sight of the mental shipwreck followis ing dementia praecox. have been unable to realize their and women whose academic or collegiate courses have been interrupted enter into The patients Young men ambition. Finally in about eight per cent. been recurrences in later followed by deterioration.172 outside seclusive FORMS OF MENTAL DISEASE world correspondingly so meagre. In still other cases there has been a stunting of mental development. of the cases the symp- toms of the disease entirely disappear. by the psychosis active find business or professional These In patients are able to care for a farm or a small business intellectual where there this is little demand for work. cases should be regarded as perfect recoveries. . because enough mental capacity retained to permit in their chosen them to maintain the battle of life narrow field. leaving the patients Not all of these apparently in their normal condition. and much disinterested in They become intellectual work that they pass their time in purely machine-like action. themselves unable to life. engaged in gardening or transcribing.

and the disappear. body shrunken. automatism. xoith negativism. and echolalia. leading in most cases. is This form characterized a condition of mental deterioration. has demonstrated exten- which he designates Even in cases where there as granular degeneration. excitement with stereotypy. first Kahlbaum in 1874. is described by is psychiatrists by us considered by a peculiar condition of stupor. J&^ CATATONIC FORM The catatonic symptom-complex. found changes in the layers. a form of dementia prsecox. and muscular tension . Nissl.tA-. with a tendency to the cell In the glia there was an increase of in which fastened about a peculiar manner. and which by several regarded as a separate disease process. There has been no special pathological basis discovered Alzheimer has described cases for this symptom-complex. with or without remissions. to running the fatal course of an acute delirium. 173 . later in the disease process. membrane fibres wrinkled. In the deeper layers of the cortex very large glia cells were found which normally appear only in the outer layer. verbigerations. which he In these he found probelieved belonged to catatonia. he found a number of cells which had undergone degeneration. cortical neurones of its the deeper The nucleus was much cell swollen. Elsewhere the cortex contained glia cells which were in sive changes in the cortical neurones. appeared to be no atrophy in the cortex.

Some one calls his name. body. Gradually the patients show great anxiety. Specks of poison are detected in the food. He hears his children cry for help. before he dies. has caused destruction of the whole . Their religious emotions become more prominent. the Virgin Mary appears. of headache. they may have suffered left ill from insomnia and loss of appetite. injects water into his limbs. complaining of difficulty of thought. and there is music in the next room. like the satellite usually subacute. but also around of it. is possessed of the devil. faces are seen at the window and pictures on the wall. and another to convert sinners. or even anxious. and he hears his own thoughts. Christ has forbidden him to eat. as He is eternally lost.174 close FORMS OF MENTAL DISEASE approximation to the degenerated nerve cell cells. and hallucinations and delusions appear. The several onset of the psychosis is with for a condition mental before depression. some one speaks from the radiator. and not only at the base of the cells. A voice from heaven directs them to do all sorts of things. spirits hover about. He no longer needs food. their work because of nervousness and have and general health. The patients weeks the onset may have appeared unusually quiet. some one pulls at his hair. and express fear of impending danger. or applies electricity to him. are inco- herent and changeable from day to day. sulphur fumes are set free about him. or of peculiar sen- sations in the head. serious. One patient is commanded to spit to the right. The patient is persecuted for his sins. where he is surrounded by angels. Little birds speak to him. Besides this. The delusions are usually of a religious nature. a priest has come to anoint him God has transferred him to heaven. There is a vision of Christ on the cross.

some peculiarities of movement and action appear. highest can cast out courts. One patient stood for hours with hands behind him and head thrown back. battles all are dead. he is surrounded by are being fought outside. ocean steamers.DEMENTIA PRECOX world . his limbs and body have run like away sive later. and possesses railroads. into Christ. is can instruct medicine. staring fixedly at the ceiling. orientation is is slightly disturbed. 175 spirits. has all power. The delusions usually become expanthough they are occasionally expansive from The patient then believes himself transformed the onset. such as rolling the head from side to side. holding the arms in awkward positions. standing or walking in an awkward manner. etc. has pleaded in the a millionaire. . has lived for thousands of years. of which constraint This may increase to a state of is the most prominent. and In another lay in the form of a cross upon the floor. all of which may be symbolical of their ideas. and while hung to a cross. the wife false. some there is a tendency to execute rhythmical movements. as in the form of a cross. his children are lost. his hands into claws. or ex- During the earlier stages of the disease pectorating at stated intervals in a fixed direction. someand the what patients do not apprehend clearly what goes on about them. They may know that they are at home or in an institution.. has all waged many wars. evil spirits. but they fail to appreciate the mental condiIn this period of depression the consciousness clouded. molten metal. his body has been transformed. his feet transformed into mules' hoofs. physicians in possesses knowledge. can create worlds. drawn off. muscular tension. The patients assume constrained attitudes. etc. his head replaced by his brain has been that of a horse.

Later they lose their early anxiety. When questioned about their ideas they irrelevant remarks. Some believe themselves trans- lated to heaven. become indifferent or contented with their environment. Some patients are even cheerful and happy. mistake those about for friends thing is and changed and that they cannot understand the acquaintances. namely: the symptoms appear catatonic stupor and the catatonic excitement. The patients may begin an act readily. that they are in a cloister or in a foreign city. or ecstatic. The patients are sad. complaining. but immediately a counter impulse checks and finally overcomes the for- . on the other hand. Following this period of depression the more characteristic catatonic symptoms appear. good except for events since the onset The attention can be maintained only attitude is The emotional the delusions at first quite in accord with and hallucinations.176 FORMS OF MENTAL DISEASE them tion of their fellow-patients. The symptom most stupor pulses is characteristic of the catatonic negativism. Thought connected. dejected. contradictory and make all sorts of The memory. and sometimes threatening. and the delusions are expressed without emotion. Occasionally sexual excitement leads to masturbation and obscenity. is much The disturbed. irritable. when interfered with. of the cases these In at least one-third at the very onset of the disease without the prodromal period of depression. for short periods. distrustful. In negativism the voluntary im- seem to be overcome by counter impulses. being incoherent and dis- patients are quite unable to reason. is of the psychosis. or they claim that every- mysterious occurrences. anxious. they are very apt to become violent.

I'i.ate 1.' . Muscular tension in catatonic stupor. producing " Snautzkrampf.

.

. is Further evidence of negativism seen in the obstinate and persistent resistance which the patients make to every attempt at handling them. to lower the hand by telling him to lift elicited it. then the together or the lips patients may become more closely pressed may move away indifferently. pinching them. off in may suddenly disappear. Some patients in this condi- tion tions. patients.DEMENTIA PRECOX 177 mer. as seen in wear shoes or stockings. and finally refuse to speak altogether. moving forward or backward. when it springs forward with a jerk. or prodding fails to elicit Even shaking a response. dressing or undressing. when the actions of the patient again become perfectly free. except them with a needle when in pain. apparently staring fixedly at paying absolutely no attention to the physician. urging him close to may get a patient to open his eyes by them tightly. when the patients They begin by speaking low. The physical origin of this resistance becomes more apparent in those cases in which the desired action is only One by commanding the patient contrawise. They resist being put to bed and being taken out. These adverse impulses tivism usually occurs refuse to speak. breaking first as the midst of a sentence or answering in monosylla- bles. The active resistance is well demonstrated by suddenly withdrawing the hand which has been placed against the patient's forehead. etc. then they may whisper unintelligibly. producing an action contrary to the desired one. Negamutism. may be persuaded to write or sing answers to quesWhen addressed they remain with closed eyes or some distant object. opening the eyes or closing them. floor rather the tendency to sit on the than in a chair. Even the most natural impulses in their stubborn refusal to are resisted.

if given a different The urine and feces may be retained until there In a few cases it is necessary to is marked distention. and face mask-like with protruded lips. While in . in or with the eyes open. eyes tightly closed. staring fixedly the distance. the eyelids closed with the eyeballs rolled upward and inward. though exhibited in several ways. The muscular tension. is most marked in the extraordinary uniformity of position maintained by the body or its various parts. or to sleep under the bed and not in closet and go to the by tbe longest route. to appear and disappear negativism. and some persist in crawling into the beds of others. The hands are very often clenched. The former may last for months. as if there were permanent contractures. The usual position is on the back with limbs stretched out.178 FORMS OF MENTAL DISEASE it. The absence of food for a week will not overcome this disinclination to take It is not unusual for this form of food voluntarily. well as the others. which is usually associated with negativism. as Sometimes the patients will begin to eat if suddenly. with his head thrown far backward. overcome this by catheterization and enemata. the face mask-like with lips slightly closed and at the same time protruded. The boy rigidly maintained this uncomfortable position for weeks. producing what the Germans call Snautzkrampf. Plates 1 and 2 represent two stuporous catatonic patients. or will remain in bed bed. In this condition patients maintain the same position for weeks and even months. This may be partially accounted for by the condition of muscular tension. the fingers producing pressure marks on the palms. They prefer to eat another's food. transferred to another building or to speak if placed in another ward. Finally the refusal of food and the retention of urine and feces are evidences of more extreme negativism.

Muscular tension in catatonic stupor. .1'late 2.

.

and hands so tightly clenched that cotton must be placed in the fists to prevent pressure While in bed she lies straight upon the back with knees strongly adducted. this This patient has been moulded into maintained until relieved. Sometimes the counter impulses seem . but is most frequently seen in the hands. backward and elevated so that the toes barely touch the the arms are elevated and drawn backward. and the Muscular tension is head is extended as far as possible. the lips protruded. with head thrown forward and knees drawn to the chin. Others lie rolled up like a ball. on tiptoes. some patients being unable to move at . Where muscular tension is less pronounced. tbe limbs is may be moulded into any position. In the extreme condition these patients may be rolled about or lifted and laid across some object without movement. which she The feet are separated. falling rigidly to the floor when raised to with unbent knees." Plate 3 illustrates this form of muscular tension. not evenly distributed. The movements are usually slow their feet others walk stiffly. The body and head are slightly bent forward with the eyes staring directly in front of her. but with the fists in the same constrained position. sores. The woman has maintained this same position for over two years without a known voluntary attempt to change it. arms. all. and lower limbs. which condition called " cerea flexibilitas. face.DEMENTIA PRECOX this 179 condition he required daily feeding by nasal tube. as rigid as a piece of wood. and arms drawn closely to the chest. floor awkward and very uncomfortable position. The gait is often influenced by this condition. the arms flexed. drawn . During this long period it has been necessary to feed her by spoon. or on the outer side of the feet with the body bent forward or backward. and constrained.

gives These opposite states pass directly from one to another Absolute silence suddenly way sant prattle. Interrupting the stupor or following and sometimes even preceding is it. While lying in bed the body may be swayed regularly back and forth. and rolling the head about after the stereotyped fashion of another patient. break the furniture. or rotating and pronating the forearm. rotating the head from side to side. A condition which seems to be directly the opposite of is negativism occasionally met during the stupor. the songs of another are sung over after them. They may run about the house for hours at a time. we have the catatonic excitement. breathing mouth. which ments. or the bed tapped at a certain place at regular intervals. churning saliva in the . the patients as if and unrestrained shouting or to incesawake from the stupor and talk nothing had happened.180 to FORMS OF MENTAL DISEASE be suddenly overcome and the movements become rapid. there susceptibility to suggestion. The is patients repeat mechanically that Questions which said to them or done before them. The patients suddenly leap from characterized bed. striking the bed or the wall in a certain place. producing echolalia and quite praxia. throw themselves upon the floor. making a peculiar blowing sound. asked are only repeated. relapse into their former stuporous state. tear their clothing. during the stage of stupor. and again in a few hours to loud it. race about the room. shouting or singing. and the actions of another patient or of the physician are repeated. by impulsive actions and stereotyped moveThe condition of excitement usually makes its appearance rapidly. is Instead greater eclxo- of increased resistance to every impulse. such as limping or offering the hand to be shaken. rapidly.

: Plate 3. 2 wF% fuJ^M V • ... Cerea flexibilitas in catatonic stupor. .fe-\ XV. j .

.

rhythmical. and drawing of the muscles of expression. . the out.DEMENTIA PRJECOX In walking they are apt to assume peculiar 181 attitudes. Another prominent symptom of this stage of the disease is the mannerisms in facial expression and speech. One patient stood for hours against the wall in the form Son and the Holy Ghost. and food. expectorating in the and clothing. or The content of speech is often quite characexplosive. knocking their heads against the wall. urinating in the bed and even washing themselves with the urine. pounding themselves. Sexual excitement very often accompanies this condition. may be clipped or the last syllable drawn Usually these expressions bear no relation to the trend of conversation." another holding his nose tightly with his hands uttered a monotonous grunt for hours at a time. wringing their hands. In the midst of their ceaseless tramping about the room they may suddenly grab at the clothing of the physician or assault a fellow-patient. sentences are likewise Words words or short repeated . jumping up and down on the bed and of a cross repeating. the eyes. " the Father. All of these most varied movements are carried out with great strength and recklessness. for the most part purposeless and impulsive. teristic. The manner of speech may be scanning. and are without regard for the surroundings or themselves. Accompanying speech winking of tbere is a peculiar gesticulation. These movements may be less constrained and regular when the patients object to another. shaking and nodding of the head. smearing with feces During this excitement the patients are very untidy and filthy. senseless The voice assumes a peculiar intonation or may quiver. consisting of a series of senseless syllables repeated in a fixed measure or rhyme. food. the jump about from one stamping on the floor.

Verbigeration excessive especially noticeable The underlining. The conditions of catatonic stupor and catatonic excitement succeed each other during the entire course of the disease. Catatonic Writing. ( ^§£2A zZ^ <3^^|g. I see you. of representing an envelope addressed to her physician. S c@Us^^ c^—^fyg&gU^^ £j&y^r-Zr&j1>Z£^S&C/^fa <&%)&ejg)(g%) Fig. " I see you. and often quite suddenly.182 FORMS OF MENTAL DISEASE patient. As in the depressive stage. in the letters. shading. 1. repeated for three of minutes. One when asked how he felt." The formation new sylla- words often accompanies the senseless repetition of bles. sample the writing tion is a of of a catatonic patient. The degree of stupor and excitement varies considerably in individual cases. making a childish babble which the patients is may repeat for hours. so also during the catatonic . and symbols are clearly manifestations of the addition The accompanying illustratendency to mannerisms.

DEMENTIA PRJECOX stupor 183 is and excitement. the consciousness somewhat clouded. Others explain them by saying that they are commanded to do so by God. Later. during the excitement. Occasionally there is noticed childish petu- lancy or irritability. but the patients seldom lose their orientation completely. mostly during the onset. and showing surprising knowledge of what has happened within their limited range of observation. Physical Symptoms. There are very apt to be vasomotor disturbances. On the other hand patients are quite unable to appreciate the necessity for their confinement or for the care of a physician. and localized sweating. The emotional is attitude after the marked dejection at the onset quite in accord with the delusions. the patients awake from this condition and give of those about them. . but that he cannot help doing them. reach During the stage of deterioration the During stupor the patients usually become quite fleshy. also encountered in a few cases. the weight rises. In spite of the fact that they seem quite unconscious of and unable to comprehend their surroundings. the patient remarking during the depression that his head is not right. the names At first there is occasionally some insight into the mental disturbance. — In some cases elevated tempera- ture varying between one hundred and one hundred and two degrees during the acute onset of the symptoms may two or more weeks. sometimes beginning during stupor. that many of his constrained and peculiar acts are foolish. dermoConvulsive attacks are graphia. There is loss of weight during the stage of depression. appearing as cyanosis. and later. telling the day and the month. This becomes more prominent during the stupor and may persist for a stage of extreme emaciation in spite of forced feeding.

These remissions more frequently appear after stupor and are followed by excitement. The memory is defective. indicating that recovery not complete. prominent feature in the course of the disease. affected or constrained manners. the stupor and excitement disappear and the hallucinations and delusions become less prominent. The consciousness of the patient becomes perfectly clear. followed by excitement. the cases the remissions are long enough for the patients to five to fifteen years. a disand a lack of full appreciation In at least one-third of all of their previous condition. are quiet illness. Occasionally the excitement precedes the stu- may even appear at the very onset of the disease. depression. passing into deterioraIn a few cases the stupor is immediately followed tion. such as irritability. seclusiveness. without mental energy. of the cases is ultimately mental deterioration. por and A occur in almost all of the cases. which rarely appears in other forms of dementia praecox. is the Remissions for a few days or a few hours remissions. The outcome in eighty-six per cent. by dementia without the intervention of the characteristic — excitement.184 skin is FORMS OF MENTAL DISEASE cold and clammy. and rational and often express a feeling of At these times close observation dis- closes a certain restraint in torted emotional attitude. They are able to comprehend simple questions. but the patients remain sluggish and indifferent. In these cases usually within two years becomes extreme. the . the heart's action slow and feeble and the bowels constipated. The usual course in the catatonic form is Course. manner and actions. seem to have completely recovered. and forced. but they lack mental initiative. tohich in thirty-nine per cent. they apprehend and remember events. It may last from In these cases one often detects ceris tain peculiarities.

and especially in the latter. are constrained and peculiar. and they are unable to acquire new knowledge. others hold the knife and fork in some peculiar fashion. Upon questioning. each bit of food being prepared and carried to the mouth in a certain definite manner. but taking ings. Many patients eat with their hands. perhaps counting three. One of my patients . They remain contented whereever they happen to be. never expressing desires. or their future. along cracks. we mannerisms which are the residuals of former stere- The movements lack freedom. with head thrown forward and with The head is usually held in peculiar cramped hands. otypy. They are wholly unfit for intellectual employment. filling the mouth to its fullest extent before swallowing. making a blowing wards. or with bent limbs. sometimes muttering to themselves. They may eat with great rapidity. tions. restless. When sitting they always assume fixed posipositions. find In both of these groups. waiting a certain interval between mouthfuls. They pass to meals only through certain doors. and unbalanced. and voluntarily in a few cases. Some of the patients are very inactive. They have no regard for themselves. or perhaps back- The mannerisms are especially marked in dressing and at table. Others eat very de- liberately. delusions and hallucinations are expressed. noise with the lips or grunting. remaining stu- pidly in one place most of the time. no interest in their surround- Other patients are active. the former are usually expansive but quite incoherent and without effect upon the bearing of the patient.DEMENTIA PRECOX 185 judgment poor. as they have no idea of how to work. shaking or nodding the head at regular intervals. their personal appearance. the patients walk on tiptoe.

Here the patients return to clear consciousness. and even becoming homicidal. which appear in all cases. seem to reof cover. They are cleanly and except for a few catatonic mannerisms might be regarded as well. and threatening. Their judgment is defective. dull. A certain number of these cases after five to fifteen years suffer from another attack which leads to deterioration. they are listless. be a tendency to form new words. distrustful. As yet there are no means of judging which cases will recover. and in a few cases resume their former occupations. expressing delusions of persecution in speech the confusion becomes marked. when the patients pro- duce a genuine word-jumble. Some of these patients . At these times the patients are restless. breaking furniture. have long remissions. especially during the transitory periods of excitement. are quiet and orderly. The most deterioration gradually deepens. There is a great tendency to perform irritable. . or lead to different degrees . are very quiet. seclusive. are able to return home. Some of these patients manifest some peculiarities in conduct and a change in character which is apparent only thirteen cent. In about per the cases patients to those associated closely with them. In twenty-seven per cent. of the cases the dementia is of a lighter grade. or over-conscientious while others are somewhat childish and silly. impulsive acts. 186 FORMS OF MENTAL DISEASE refused to eat unless he had been allowed to stand on his head and crawl under the table. lack energy and endurance. attacking individuals. Similar mannerisms are In speech there may also evident in speech and writing.. and especially folal- lowing short periods of excitement. with shouting and laughing. But a profound change in the character is noticed their former mental vigor does not return.

Die Trage die Katatonie oder des Irreseins nur Spannung. 515. S.. Clearing of consciousness without proportionate improve- ment in the emotional attitude. The fatal termination of the catatonic form usually occurs as the result of some intercurrent disease. 1004.. 241. 187 This much can be said. Bd. Psychiatrie. f. ibid. however.DEMENTIA PRECOX of deterioration. Bd. Behr. BIBLIOGRAPHY Kahlbaum. 1881. of which tuberculosis is the most prominent. Die Katatonie oder des Spannungsirresein. as pa- have remained in stupor from three to five years. Monatschrift Psychiatrie uud Neurologie. The mere presence of prolonged stupor does not tients necessarily indicate deterioration. point to deterioration. inactivity. that those with rapid and more acute development are more apt to have a remission than those with a gradual onset.. The special predispositions for this disease are shallow respiration. Allgem. Aschaffenburg. 6. and untidy habits. 54. Tscbisch. 1874. Diss. Dorpat. S. Zeitschr. Schule. . f. with persistence of man- nerisms and the appearance of short periods of excitement. S.

intriguing against them. and also because of the occasional acute onset and the frequent occurrence of single catatonic symptoms. with retention of clear consciousness for a considerable time and rapid appearance of mental^ deterioration. and neologisms. While there are many delusions and hallucinations in the hebephrenic and catatonic forms of dementia praecox. seem depressed and anxious. term are by many psychiatrists considered as forms of paranoia. In a short time they divulge a host of entirely almost of persecution . are characterized by the great promihallucinations and persistence of delusions and for several years. a view which in our minds is untenable. are unusually devout. following a period loss of of headache. and insomnia with a rapid energy and often irritability. they are not wanted at home. people are watching them. because of the comparatively rapid appearance of mental deterioration. The First Group of cases is characterized by many incoherent and ever changing delusions of persecution and grandeur. malaise. and remain alone. delusions. former friends are talking about them and trying to injure their reputation. which. These delusions 188 . they are never very prominent and usually disappear as The cases grouped under this deterioration progresses. The patients act peculiarly. The onset of the disease is gradual.PARANOID FORMS The paranoid forms two groups of nence of dementia praecox. and a light grade of motor excitement. mannerisms. include cases. such as stuporous states. in spite of progressing mental deterioration.

or a crowd of men throwing stones at the window. have been nominated for tinge. They mistrust the attempt suicide. In a paroxysm of fear they may even The consciousness usually remains unclouded. DEMENTIA PILECOX are changeable and soon become fantastic. and have journeyed over the whole universe. they have been shot down into the earth. The patient pressive and more expansive and fantastic.. The emotional attitude before long loses the sad and anxious by a certain cheerfulness and exaltaAt the same time the delusions become less detion. spirits Their intestines enemies and are being replaced a little at a time . Patients during this time are anxious. them bastards. Halluhearing. have visited other worlds. their throats occluded and the blood no longer circulates. 189 The patients claim that some extreme punishment has been inflicted upon them. being replaced . surroundings. have lived many lives. threaten them. and boasts that he has been transformed a female is pregnant by the Holy Ghost into the Christ others will ascend to heaven. men. They are transformed into stones. Occasionally faces and forms are seen at night. are very prominent during like other call fellow-men jeer at them. this stage eat. accuse them of awful crimes. restless. Messages over the telephone are overheard mentioning that they are about to be sent to prison. and emotional. they and must undergo all have been removed by cannot talk. in spite of persecution is happy and contented. can surpass famous war correspondents. Foul vapors may be thrown into their bedding. their countenances completely altered. their own heads have been removed. have been transformed into sorts of torture. . at times becoming aggressive and violent. especially of . They have the talent of poets. agitated. or walk cinations. extravagant and talkative. etc.

Some of them fill hundreds of emotion. A patient will say that he is . almost as absurd and extreme. to ideas. are wrecks of a dreadful struggle with enemies. expressing freely their many delusions. the greatest inventor ever born. where they were exposed to furnace flames. . Associated with these variegated and ever changing expansive delusions are delusions of persecution. is endowed with all the attributes of God. The writings likewise become more and more unintelligible. because of the number of peculiar phrases and expressions to which they attach special significance and freely repeat.190 president. but expressed without corresponding While laughing they may complain that they have been deprived of their limbs. and relevant manner. are answered in a coherent another. FORMS OF MENTAL DISEASE and have represented governments at foreign These delusions may become most florid. but later there loosely expressed that it is is such a wealth of ideas difficult to find any system them. can create mountains. however. ever existed. having been pierced with thousands of bullets and been thrown into hell. sheets of paper trying to describe them. can talk to the people in Mars indeed. Suggestions for many of these delusions may arise from pictures on the wall or from reading. is unlike anything that has all light knowledge. the speech becomes . can prophesy for coming ages. Later in the course of the disease more and more difficult of comprehension. that and darkness emanate from him he possesses is an artist. They wander aimlessly about from one delusion showing frequent repetitions of the same Questions. and all ridiculous. foolish. a star. courts. These patients are usually talkative. At first they are in quite coherent.

they are self-conscious. and nize relatives. — There may is physical dis- turbance except the loss of weight and insomnia at the onset.DEMENTIA PRECOX 191 The patients rarely possess insight into their condition. and are adhered . The years. often in connection with the menses. Many of the patients are able to perform some mechanical work. The Second Group hallucinations of paranoid cases is characterized by and fantastic delusions of persecution and of grandeur. it but they soon become unable to use in reasoning. although a few show restlessness. with an important bearing. Physical Symptoms. special attention. which incapacitates them for all mental application. often designated as celebrated personages. The course is progressive without remissions. While active and somewhat interested in their environment. rarely depressed. but the content of thought become thoroughly incoherent and there is a lack of energy and plan in their activity. The consciousness becomes somewhat clouded later in the disease. which are mostly coherent. some and occasionally some passion. They recog- and can give a fairly clear statement as to recall where they are. of and are usually well marked by the end two The patients may for a long time retain clear conscious- ness and partial orientation. They cannot apply themselves to any mental work. and demand patients In emotional attitude they irritability are almost always exalted. very little but need supervision because of their lack of application. Orientation as to place is least disturbed. but people are soon mistaken. They may some past knowledge. they still display a self-conscious serenity. with interference of nutrition. all conception of time is lost. The patients show an exaltation of the ego with heightened feelings. signs of mental deterioration appear within a few months.

remarks are made which refer to them. such as the blowing of whistles and the ringing of bells. The first symptoms to appear are those of despondency with some self-accusation. which. rarely of sight. Coherent delusions of persecution develop gradually. have committed some crime. when they disappear. In public places. They complain that the food contains poison which they can taste. Enemies take advantage of their confinement by standing below the window calling them all sorts of names. leaving the patient in a state of moderate deterioration. people watch them. peculiar actions are noticed. and children on the street jeer and laugh at them. They fear that they have done wrong. . acquaintances are less friendly. and seek religious advice. and are to be put to the rack. Hallucinations. aiding in the elaboration of the delusions. however. All these incidents have a hidden meaning. society. especially of hearing.192 to for a FORMS OF MENTAL DISEASE number of years. are prominent at this time. are misinterpreted in accord with their delusions. they are unusually devout. They are libeled in newspapers. The patients are troubled with thoughts of death and religious doubts. They are making their own observations and will be ready to expose the offenders and bring them to justice at the proper time. perhaps mimicking their manners. in the cars and at the church. that they have committed murder. Voices are heard from the walls and from under the floor stating that they are wretches and outcasts of Very often the noises really heard. is fully understood by the patients. home are unsatisfactory is : the children are differ- and the husband or wife unfaithful. or are suffering the penalty of self-abuse. Affairs at ent. Passers on the street who are entirely unknown to them turn and stare. announcing that they are to be imprisoned.

hypnotism. They are compelled to act contrary to their distasteful things. They attribute the origin . such as Objects in their surroundings are changed in order confuse them. but- tons are missing. The means employed by mentioned. X-rays. specks before the eyes. An itching of the foot is sufficient evidence that a poisonous powder has been blown into their shoes. snicking. telepathy. and cramp in the bowels. Others complain that their minds are influenced.DEMENTIA PRECOX 193 they suspect phosphorus in the tea and detect kerosene on the clothing. as. These are accountable for the most and electricity. physical discomfort are varied. pain in the back indicates that they have been shot there while asleep. It is quite characteristic for the patients to refer to these physical changes by some invented names. is is the result of poisonous vapors. their thoughts are gone. lobster cracking. which in spite of themselves are always evil. then replaced out of own will and to say Organs of the body are removed and order. a frontal headache in order to destroy their intellect. they have no control over their thoughts. and the intestines are shrunken. ugly duberty. known agencies are magnetism. there to a rip in the coat and a pocket somatic sensations. all various sensations in parts of the body. Something is placed in their food to create sexual the persecutors for producing All excitement. headache. pain about the heart. Many twitching of individual muscles. notice that their is clothing is changed. are all evidences of injuries caused by their enemies. such as. which are set free in the room at night A tremor of the fingers produced by means of electric currents sent through the air. They torn. The explanation of these somatic hallucinations often takes fantastic forms. etc.

cause the testicles to fall and the throat to dry up. but centres about the delusions. contradictory. Then the delusions are incoherent. These are as variegated and fantastic as those of persecu- The patients have been awarded a crown for bravery and ful dresses. mense trusts which they are to manage. as deterioration appears gradually in the course of several years. now rule over some country. rapidly. all cases. causing the bones to crack and the head to rattle obscene remarks proceed from the stomach their ears are rilled by They all sorts of noises made by these spirit-possessors. The consciousness during the development of these delusions. All of the many delusions expressed by the patients are at first coherent. .194 FORMS OF MENTAL DISEASE which are forced upon them of such thoughts to others in spite of themselves. but later. . remains clear. The patients are oriented. and show a tendency to some course of reasoning. They represent the Pope and are to travel all over the world. God daily appears to them and gives them a blessing. and unstable. Many patients appre- ciate that they are not normal. perhaps years. The patients are able at first to offer some basis for the delusions and to refute objections. but after a few years they become quite incoherent. and for a long time afterward. Ideas of spirit-possession are often a prominent feature. They have recently been entrusted with millions which they They have consummated imare to invest in mining. . Here the enemy enters and takes possession of the body. Thought is coherent. is and change There ail- rarely insight into the disease. but their defects and ments are all regarded as the works of their persecutors. Expansive delusions are also present in almost tion. possess beautiand are betrothed to the king. thought becomes cloudy and confused.

first The course is slowly progressive to mental deterioration. In con- versation the patients are incoherent and unintelligible. The outcome always deterioration. journeying about to get rid of their enemies. and a lack of appreciation of and conformity to external relations. The delusions in the course of several years cease to further develop and gradually fade away. then a prominence of delusions of persecution. but later. later the appearance of the delusions of grandeur. place metals in their shoes or wires in their clothing to divert the electrical currents. In accord with expansive delusions air. applying to police for protection or. and use There are no definite physical symptoms. with occasional references to former delusions. seen in lack of judgment. assume a superior high-flown language. taking the . and absence of mental energy. and finally the fading away and is entire collapse of the delusions. they attack supposed persecutors or attempt to expose them through the papers. but later this gives way to a certain amount of happiness and cheerfulness. they may decorate themselves in fantastic costumes. one can discern certain stages. adorn themselves with badges. matter in their own hands. Remissions have occurred in a few cases. In their actions they show many peculiarities. indicating the onset of deterioration. Others contrive a sort of armor for themselves.DEMENTIA PRECOX The emotional 195 attitude is at first characterized by depresand anxiety. they are suspicious. with considerable sion egoism. In conduct and manners the patients may at first be quite orderly. in accord with their delusions. They . leaving the patient with a certain degree of mental weakness. At a change of disposition. Ideation is scanty. there is However.

refusal of . and are accomThe accompanied by stereoetc. If mutism and refusal of food are present. distinguished from the hebephrenic form that the hypochondriacal ideas are not is the judgment no evi dence of_ deterioration. and thought. but they are unstable and transitory. nerisms.'attention. except . and the "queen" a good seamstress. impulsive actions. and sometimes are even industrious. especially in memory which in dementia paralytica is both rapid and profound. of judgment. — food and mutism. The disease is distinguished from dementia paralytica by the earlyage of onset (fifteen to thirty). It is differentiated from amentia by the absence. there is patients are not stupid. they are less obstinately carried out panied by a more \ marked clouding o f_consciousness. excitement in dementia paralytica. the retention of apprehension contrasted to the great stupidity and indifference of the paretic. negativism.196 FORMS OF MENTAL DISEASE are usually capable of employment. and stereotypy Man- { may appear in dementia paralytica. Finally the presence of physical signs speaks for dementia paralytica. sign of dementia prascox. mutism. the former " Pope " becoming a trusted farm-hand. the and finally they improve with The presence of ha llucination s is a positive treatment. less loss retained. less jopid development of deterioration. Finally they reach a stage of apathetic deterioration. Diagnosis of Dementia Praecox. is — Acquired neurasthenia by the fact silly. are incapable of when they any employment.. is distinguished "• l from the catatonic excitement by the great disturbance of *apprehension. typed movements. The contrariness and obstinacy of the paretic are usually unaccompanied by other signs of negativism.

/ In amentia the patients are at all times quite unable to carry on a con- and talk incoherently of their past experiences. namely. the ^ uni form emotio nal attitude. and stubborn resistance to if pain is produced by pricking.} while in manic-depressive depression the feelings are apt to be intensified. while at times they are monosyllabic and entirely incoherent and silly. while in J dementia prsecox they are sluggish or indifferent in apprehending. by the gradual onset. they occasionally surprise one by the recitation of knowledge of their versation. as well as an emotional attitude which does not correspond to the depressive character of the delusions. remain quite indifferent during the of visit or at the death a relative.' ner vous exhau stion. conditions of negativism of The apparently similar the catatonic and of retarda\ tion of the manic-depressive are at times^ distinguished only with difficulty. earlier days.S every passive movement. contacts are resisted.} Voluntary movements . In the former there^is uniform. while in j amentia there is complete dis- orientation/ In amentia the patients do maintain attention to the surroundings. and by the le ss mark ed clo uding of con sciousness the patients are at least par. In dementia prsecox. there drawal without passive effort at defence . of the characteristic exciting cause. The greatest difficulty arises in distinguishing the de- pressive form of manic-depressive insanity from the period which one meets at the onset of the hebeThe early appearance of many hallucinations speaks for dementia pi'cecox. The patients of depression phrenic and the catatonic forms. and a simple with- while in retardation the in the catatonic stupor movements are permitted and painful.DEMENTIA PRECOX in a very 197 few cases. is rigid. contrasted with the rapidly changing emotional state in amentia. tially oriented.

In the icatatonic form there is greater disturbance of conduct. apprehension and fear. or irritable. Thejcatatonic speech abounds in verbigerations and s tereotyped ex pressions and is free of comments upon the surroundings. ret arda tion all voluntary movements are carried out very There is sometimes a certain resistance due to slowly. dependent upon ideas. frequently repeated. The movements of thejcatatonic are pur posel ess. but this is active. the patients being pareven in the greatest excitement. impressions. and is centred upon or drawn largely from the immediate surroundings) has less motor excitement to follow than that of the In this condition attention is readily distracted_by the sur- roundings. while in the] maniac there is greater disturbance of apprehension. and emotions. orientation. and always appearof thefcnaniac in whom the movements are always ing in new forms. while in the/extre me ^m aniacal state there is complete jiisorien tationr On the other hand the speech of the catatonic who is more senseless and difficult maniac who has extreme motor excitement. exalted. The excitement of the catatonic is to be distinguished from the excitement of the maniacal forms of manicdepressive insanity. childish. the content of speech and emotional attitude. in contrast to the pressure of activity pu rposeful wrbh some relation to the surroundings. except when these movements In are made by request.198 are rare. but FORMS OF MENTAL DISEASE when executed are carried out without delay. is less marked than in the maniacal excitement. The increased activity of thejcatatonic . tben there is always delay. and at times even rapidly. while the speech of the imaniac presents the characteristic flight ofjdeas. while the attention of the ca taton ic cannot be The attitude of the catatonic is silly. and thought! In the catatoni c excitement the clouding of consciousness tially orient ed.

sexual ex- citement and remissions attitude is uni formly na tural.DEMENTIA PRECOX is 199 more apt It is to be limited to one corner of the is room or of the bed? while that of the maniac limited only by his confines. sometimes extending over one year with only a few hallucinations. with an absence of system and a failure to harmonize them with events of their past i life . hallucinations and delusions are more\exaggerated and prominent in the catatonic! The distinction between the paranoid forms of dementia prsecox and pure paranoia depends upon the j lack of Vystem. but the fdelusions never disappear. the rapid development of fantastic delusions commencing with prominent Tiallucinationsj. while in paranoia the delusions are largely confined to morbid Snterpretations of re al even ts. usually able to detect >^lyness and ^method in the contrariness and pur- pose in the actions. the de meanor. The delusions in dementia prsecox are extremely fantastic. . catatonic sometimes necessary to differentiate In the latter one is excitement with epileptiform or hysteroid attacks from hysterical states. and co ntrad ictions^and objections are appre hende d__and_explained. while in the catatonic there senselessness is evident and lack of purpose in exhibits movements. changing beyond all reason. — depression . while in/paranoia the onset is very gradual. and the stupidity. gradually becoming extended to include even events of recent date. or silly elation.is almost normal. while iniparanoia the emotional In paranoia there may be partialjvemissions when the patients react less actively to the delusions. In emotional atti- tude the dementia prsecox patient soon shows clear and marked changes. and the patients are capable of occupa tion for a long time. j emotional attitude more Finally. are woven together into a coherent whole.

of 'excitement with 4mpulsiveness. in the catatonic they are purposeless and stereotyped. of the catatonics and eiglr^per^cent^of the _ and )none _o£_the paranoid form. which seem to have recovered may suffer from another attack later in life. The degree to which the mental impairhebephrenics recover. imbecility may be confused with the end stages The differentiation then depends of dementia praecox. is sufficiently indicated in the discussion of the course of the disease in the different forms. as the vast majority of cases end in mental deterioration. is The prognosis of dementia prsecox unfavorable. Even the few cases ment advances Treatment. upon the presence ok transitory periods evidence of earlier sch ool knowledge. and the presence of ecstatic^ attitude and a more profound disturbance of conThe actions are prompted by fee lings.( and the occasional expressions which give The dreamy states of epilejrtic insanity are distinguished of- from the stupor the catatonic form by the an xious resi stan ce contrasted to negativism. which leads to deterioration. this varies in the different forms . those with the acute and sub-acute onset. Almost all cases. Exception is made for the few cases of the hebephrenic form with insidious onset. while sciousness. and to symptomatic treatment. At the onset of the acute and subacute cases\bedtreatment should be prescribed . As already stated. thir- teen per cent. for all cases. care in order to prevent injuries to self establish a suitable and especially demand hospital and others. These patients may be cared for at home with safety for a considerable time.200 FORMS OF MENTAL DISEASE In the absence of history of the early life and of the psychosis. — Our meagre knowledge of the causes of the disease restricts the indications for treatment to the individual jjymptoms.

hypop hosph ites where feeding by nasal or _stomach In this event 'or alcohol should be added to the liquid nourishment. however. and good self-control. and frequently require the supervision If these measures fai l to allay the e xcitement. as well as the digestive organs need careful This is especially important in the stuporous states of the catatonic. a well-trained. of which sulphonal or trional in ten to fifteen grain doses are the best. or simple occupation planned to distract the attention from self. a kindly disposition. at least temporarily. by prolonged_warm ^ tA^ 89). are important features in the psychical treatment. is necessary to maintain nutrition.DEMENTIA PRECOX 201 Insomnia at the onset may be controlled by lukewarm baths or sparing doses of a hypnotic. In the condition of depression at the onset of the disease the patient should be irritation. 246). In the case . are not subject to periods of excitement. or hyoscine hydro- bromate 2To without some - ^ gr - These. tube eggs. tactful nurse or physician often succeeds in bringing about quiet. nothing remains but confin^mentjn_a_padded room with careful watching. The condition of nutrition attention. at s ulpho nal. but this requires great patience. preceded by trional. are not applied risk. After the subsidence of the acute symptoms. Frien dly removed from all sources of encouragement. Simple persuasion on the part of of a physician. in which event one can employ cold packs (see p. with change of environm ent from time to time. provided the patients are not untidy. especially in the catatonic form. yield to the simple may not often first successfully warm bath. Condil4 tions r-fff baths of e xcitem ent are best treated (see p. The extreme excitement sometimes encountered. is it desirable for them to return to their homes. and are able to take sufficient nourishment.

Rivista sperimentale di freniatria. 43. preferably with outdoor environment. Annales Medico-Psychologique. Contribute clinico alia doctrino della Demenza. women These patients years. T. 5. 180. X. as a result of increasing deterioration. . Precoce. De la Demence . XXV. Praecoce. 200. inhibits further This means often development oTdeterioration. BIBLIOGRAPHY Tinzi e Vidriani. 177.202 of FORMS OF MENTAL DISEASE one has to consider the possibility of pregnancy. they drift into it almshouses or back into insane hospitals. 420 T. Christian. T. IX. essential Finally is most that the partially demented persons should be engaged in some re^ular_employment. but may reside comfortably at home for many finally.

less This disproportion more often from gradually decreasing. a chronic progressive psychosis of middle age. Etiology. years. appearing before twen ty-five or after fi fty-five years of age. probably the result of autointoxication. ilized — The disease is is unknown among the unciv- most prevalent in western Europe and North America. of the admissions to large foreign city insane institutions which now admit twenty to thirt y per ce nt. It occurs most often between thirty-five and forty The onset is late r in wo men than in men. while in farming districts the disease is very rare. and pathologically by a fairly definite series of organic changes in the brain and spinal cord. of paretics. the depressive form and least often from the agitated The disease is more often one of mi ddle l ife. Early in the past century the disease represented about five per cent. suffer 203 W omen . of cases appear in large cities By far the greatest number It is and manufacturing centres. rarely form. and standing. It seems to be a disease of modern Not many years ago the negroes were free civilization. lead- to absolute dementia and paralysis. at the present time its percentage of among them almost reaches that the whites. characterclinically ized by progressive mental deterioration with symptoms of ing excitation of the central nervous system. is or general paresis of the insane.DEMENTIA PARALYTICA Dementia paralytica. from four to five is times more prevalent is prevalent among men among women of high than women. nations and from the disease .

_ Defective heredity - is found in fiftyjier cen t. S. and excesses in eating and drinking. to the experience of at According Gudden in the Charite and Kraepelin 2 Heidelberg a clear history of syphilis cannot be estab- lished in more than the thirty-four per cent. 3. and married women are usually Occasionally the disease occurs in man and childless. Allg. sometimes tabes is present in one and dementia wife The male patients are drawn paralytica in the other. of cases. especially more frequent among the unmarried. from all classes and from all professions and trades. The disease is prostitutes . tia and alcoholism were frequently found in the parents. . Berkely at Baltimore offers the same percentage. f. paralytica. is Among~the prominent. insolation. accompanied by a general and extensive destructive process involving not only 1 2 Alzheimer. Alzheimer has recorded syphilis The juvenile form is in seventy per cent. Other causes are alcoholic excesses. from eleven to seventy-seven per cent. syphilitic The and the onset of dementia paralytica varies between two and twenty years. but more often occurs between ten and twenty years later. of cases. and mental shock.204 FORMS OF MENTAL DISEASE Kecently a number of cases have been reported between In these cases of dementhe ages of ten to twenty_years. Zeitschr. head injury. causes of the disease syphilis the most Its prevalence varies. syphili s 1 usually that of simple deterioration of long standing. In view of the uniform course of the disease leading to dementia and physical paralysis. according to various authors.. coincident with the struggle for existence in large cities. Psy. of these cases. of which alcohol is by far the most prominent! Another important factor is the restless oy erperiod between disease active life. 52. with great prevalence of paralytic attacks. Bd. .

If one accepts the view . and the entire vascular system. The high grade destruction of the neurones. all speak for the pr o- found dist urbance of nutri tion. their rapid destruction. and it the body. These anatomical facts are wholly in accord with the clinical observations. the alternate loss and increase of the bo dy weight. and finally the paralytic attacks. heart. as well The sudden and h igh as the prolonged subnormal temperature. would speak for the sudden overwhelming of cortical neurones with a toxin. excitation of the neurones . We have the symptoms of s yste m. can best be explained by intoxication arising from disturban_ce_ot_^oetabolism. While the involvementTof the blood vessels and the broad extent of the lesion indicates that the toxin reaches the neurone by means of the blood vessels. some of which almost approach co mplete regflyery. the occasional exacerbations of the symptoms. rapid or gradual d eteriorati on and marked re missio ns. "judging from our experience in eclampsia. namely: the gr adual o nset. great clo uding of con sciousness. or clinical picture. myxedema and uremia. encTmg at last in greaT"emaciat ioa. grad- ual sclerosis. yet the disease of the blood vessels stands in no definite relation to the anatomical The involvement of the kid neys. ele vation of temperature. but also the general vascular to a limited extent the inter nal organs of seems probable that we have to do with an autointoxication process. and the possibility of a regeneration of the neurones. and which has been regarded by Lissauer as the cause of the paralytic attacks. the f rag ility of the bones.DEMENTIA PARALYTICA 205 the central nervous system. all of which can be reproduced by experimentation upon test animals with any toxic material which causes a destruction of the neurones. which has been demonstrated by Nissl in some cases.

206 FORMS OF MENTAL DISEASE that the toxin circulates in the blood. then the difference in the intensity of the destruction of the neurones and the paralytic attacks indicative of focal lesions in the cortex can be explained by the difference in the concentration of the toxin and a varying of the toxin still susceptibility of the cells in the different areas. It will be impossible to accept a view that syphilis is the cause of dementia paralytica until we can establish a history of syphilis in more than thirty-four per cent. seems probable that in from a profound disturbance o f metab olism. dementia para- cannot be regarded as a simple syphilitic disease. while the dementia characteristic of dementia paralytica does not occur in the greatest number For of cases until after ten or this reason more years have lytica elapsed. of cases. Strumpell draws an analogy from the symptoms of paralysis in diphtheria. Late manifestations of syphilis arise within a comparatively short time after primary symptoms. It is possible we may be able later to distinguish a difference in the dementia paralytica following syphilis and that following that Thus far only a few cases can be selected which show a gummatous infiltration of the walls of the other causes. the production of which in a considerable number of most prominent factor. Moeand others go so far as to hold that both tabes and dementia paralytica are late manifestations of syphilis. The character it and the sources from which It arises it are questions arises in doubt. . claiming that dementia results from the effects of a toxin which develops in consequence of the presence of the syphilica.ses\sy2)hilitic infection is the bius tic virus during the early stages of syphilis. vessels of the brain. a view which seems to be borne out by the experiments upon nine paretics cited by Krafft-Ebing.

which of of dementia paralytica. the fro ntal lobes increased in The lepto meningitis is always more intense over the poles o f The Pacch ionian granulations are usually . and to a less extent in the central convolutions. The dura adherent to the calvarium in places. to a thick. and excesses. In thirty-three per cent. parietal.DEMENTIA PARALYTICA 207 On the other hand in a considerable number of cases syphilis in some way is in a position to produce profound develops changes of metabolism the direct cause from which a toxin. size. white membrane. The vessels. The falslTmembrane is almost always on the vertex over the frontal. from a thin. Such a view obviates the difficulties in making a satisfactory explanation of the acteristic is the pathological changes char- relationship Other etiological between syphilis and dementia paralytica. whitish. The convolutions are atrophied. with small or large. lead. with or without thickening of the present. clots. are occais •enumerated can as a whole be nomic of sionally this disease. or temporal lobes. fresh or par- toma are situated tially absorbed. Pachymeningitis. — The pathological changes here regarded as pathogexostoses of the tables. especially in the frontal lobes. interna and hema- common. almost imperceptible rust-colored membrane. Hyp erost oses and usually cranium. as alcohol. relation to this disturbance of would bear a similar causal metabolism. of cases the p_ia over the atrophied convolutions and broadened fissures~is ed ematous. and translucent along the especially over the ver tex of the frontal and and parietal lobes and the first threejtemporalconvolutions. Pathological Anatomy. pia is thickened. The internal surfaces of the frontal lobes are usually adherent. and is of varying thickness. factors. In these portions the cortex is narrow and often . firm.

and the choroid less marked. tearing upon its removal. and in sonie~"cases of long duration may is be reduced to nine hundred grams. which should be compared with Figure 1. corresponding to the more severe and represents a normal rapid course of the disease. cytological changes of varying intensity are found scattered throughout the cortex. cell. plexus contains man y cysts ! The ependyma. Plate 4. progressive!! Paralyse. Die Pathologische Histologie der Grosshimrinden-Erkran1893. the atrophy is much The ventricles are dilated. f. is usual glistening a frosted appearance.. Nissl. so that the axis cylinder process can be traced for some dis- tance from the body. surfaces The weight of the brain is regularly below the norm al. kungen bei der allgemeinen .208 FORMS OF MENTAL DISEASE strongly adherent to the pia. Psy. 1 Microscopically. S. 989. and the corona radialis is shrunken. Archiv f. consists of a swelling of the body of the cell nucleus. 28. Bd. This change is represented by Figure 2. and in the basal ganglia. Where the process has which been more intense. which in many cases has undergone hyaline degeneration. 172. and cell staining of the ac hromati c substance. 53. Bd. and the whole appears very much as if it had been perforated with 1 cell fine Binswanger. Heilbronner. Psy. In the other portions of the cortex. The average weight eleven hundred and sixty to thirteen hundred grams. These granulations are composed of an increase of neuroglia. Zeitschr.. in the chronic neurones may These changes be divided into the acute and the the character of corresponding to the clinical symptoms. especially of the fourth ventricle. The and its acute change. as observed when studied by the Nissl method. the chromatic substance breaks up completely. Allgem. and the inner walls of the lateral vencovered with granulation s. S. the nucleus swells out. which give the tricles.

1 Fig. 5 — Chronic cell change in dementia paralytica. 2 — Acute alteration in dementia para— Normal large pyramidal Fig — Grave alteration in dementia paralytica. Fig. 4 — Cell shrinkage Fig. 6 Plate 4 Fig. fi — Chronic change with superimposed acute change in dementia paralytica. 4 Fig. Fig.Fid. . Fig. 1 cell.i Fig. . in dementia paralytica. 5 Fig. lytica.

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however. encountered also in other destructive lesions. which seems Another change which apparently belongs among the chronic changes. which. consists of an immedia te the structure. cell shrinkage should be regarded as a severe and irrep arable change. In some cases the normal and the abnormal cells may be found lying along side The chronic change of each other. . dissolutio n of the cell loses its body with a shrinkage of its nucleus^ which membrane and characteristic becoming round and staining a unifo rm vi olet finally The nucleus remains as a small structureless cell clump. The nucleus appears ." (Figure It consists in a fading away and a shrinkage of the 4). 209 This acute change uniformly The most is the neurones of the entire cortex. The nucleus is also involved . so that the nucleus superficial observation may seem is to be increased in size. The achromatic substance affected only very slightly. the nucleus loses rotundity. Apparently. ThiiT process do es not permit of restitution. however.DEMENTIA PARALYTICA shot as seen in Figure involves 3. such as the nuclear cap and the is called basal bodies. remain uninvolved for a very long time. differs from the acute in that no t all the neurones are equally involved. especially about th e base is it s triangular or oblong. with or without scanty residuals of the possible in the other processes of the acute type. Some portions. producing sharply stained bands. by Nissl " cell s hrinkage. There is a gra dual sclero sis of the neurone. chro matic portions. profound type of the acute change. blue. body. and the membran e cell l folds upon itself. the axis cylinder may be recognized and traced. achromatic portions of the structure The chromatic and ose their charac teristic at the and stain profusely. however. its membrane upon partially or entirely disappears. the cell body shrinking and becoming irregul ar in outline.

parietal . or surrounded by areas^composed only of sclerotic tissue and vessels with thickened walls Figure 3 should be compared with the normaTcortex as repre. The nerve fibres of the cortex and the corona radialis present anatomical changes which bear a definite relationship to the extent of the process in the nerve cells. word deafness and convulsi ons. It often happens that cells with this of a supe rimposed acute process. their processes.210 FORMS OF MENTAL DISEASE cell. Where the clinical course has been prolonged and the neurones are much degenerated there remain but a very few normal fibres. and an atrophy of the cortex. This degeneration may be more m arked about the vessels. except where there are speec h disturbances. there is As the result of the degeneration of the nerve cells as seen in Figure 3. In the darkly stained portions one The chronic change often sees fine. Similar destruction of the nerve fibres may be found in se nile dem entia and epileptic insanity. As yet no relationship has been established between the symptoms and the pathological changes in the different areas. clearly stained bands. and central convolutions. either closely pressed together. periphery of the in their shrinkage take on a star-like formation. It is this anatomical condition which is . as seen in Figure areas is chronic change give evidence 6. which in extreme cases may shrink to_one-half its normal width. The smaller pyramidal cells is represented in Figure 5. in which cases there is clinical uniformly found involvement of the temporal. The remaining cells are no longer arranged uniformly. but it is not as far advanced as in dementia paralytica. The resist- difference in the intensity of the process in the different probably due to difference in the power of ance of the neurones. sented in Figure 2. but are turne d in all direc tions. Plate 5.

Fig. . » » * -« > i . . »••* V\* .r?sf WT7^ J: • V » ' ^> -' 1 y^. T Vf' k :> v.. g — — — — — — cerebral cortex in dementia paralytica.. .« R. j. 5 Showing the relation of spider cells with vessel walls in deep layers of Fig.-'' '/r°--i • • u't- '• \'*. .^/A. . . » - J •.J] i- •. 3 Cere1 Cerebral cortex in idiocy..*•. Fig. Fig. * ' /. •• >•. Fig. bral cortex in dementia paralytica.»> ft 4. 2 Fig. * * < t Fig.•*• < L. 2 Fig.. 4 Glia in normal cerebral cortex.<. Glosis with presence of spider cells in cortex in dementia paralytica. .«! •>/ . -*r. Normal cerebral cortex.' » . Fig.. . .

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their wal ls thicke ned and Some of the vessels infiltrated with many r ound cel ls. and even in dementia prsecox. and others show totally are are dilated. Thi s great increase of jspjder cells may be seen in Figures 5 and 6. Vascular changes in the cortex form a prominent part in the microscopical picture. Plate 5. (butjn none do all the elements of the cortex suffer to such a profound degree as hereTJjIn senile dementia. on the other hand. even when the process is not far advanced. The cranial nerve nuclei of the medulla show similar changes to those seen in the cortical cells. a few small aneurisms. also present degeneration of and cerebellum Weigert has the neurones. The vessels are increased in number. with a de struction of the Purk inje cells and their processes. The cell changes already described may be found in other conditions. The basal ganglia. is This distortion with the presence of scar tissue present to a recognizable extent in dementia paralytica. central gray matter. and. in which the spider cells take a prominent part. which represents the normal amount of neuroglia present in the cell cortex. demonstrated an increase of neuroglia in the granular layer of the cerebellum. . in comparison with Figure 4. oblit erat ed. as correspond to the destruction of the nerve often normal nerve cells are surrounded by considerable neuroglia. The increase in neuroglia does not necessarily cells.DEMENTIA PARALYTICA 211 most characteristic of dementia paralytica. in the same areas all the nerve cells may have disappeared. but the general conformation of the remaining elements is undisturbed. many cells and fibres are destroyed. idiocy. In the areas of degeneration there may be a considerable increase in the neuroglia tissue. without any appreciable increase of the neuroglia. appearing especially in the deeper layers of the cortex and about the blood vessels.

Of these at heroma of th e aorta and arteritisof the vessels of the liver and kidn ey are the most prominent.. 24. Fuestner. are entirely lackEven cases of apoplectiform attacks. 39.. and ove rlook importan t matters is The attention maintained o nly w ith effort.212 FORMS OF MENTAL DISEASE Gross brain lesions. Bd. such as we should expect to find where there have been paralytic attacks. Virchow's Archiv. H. Archiv f. f. present no lesions. the being deg eneration of most important anatomical changes the fibres in the po sterior and lateral Fuestner columns. changes are occasionally found in the peripheral nerves. in daily life.. The spinal cord 1 is involved to a greater or less extent in almost all ca ses. Long sentences are followed only with difficulty. i is apparent an increasing difficult y of app rehension of external impres- The patients natte ntive. Archiv Psy. 20-21. Westphal. followed by ing. hemiplegia or aphasia. Psy. — From the onset there are di strac tible. 1 A con- Psy. 12. I. The two sides are uneve nly aff ected. the conscious ness beco mes clouded. Westphal. and bits of wit are lost upon them. Bd. Westphal. In this Business obligations are poorly performed. f. Bd. 1. found them alone only in twelve to nineteen per cent. . Symptomatology. recognize former well-known objects and circum- stances. Bd. of Degenerative cases. and unable to grasp clearly and sharply the character of the environment. In the internal organs vascular changes are so frequently found that they seem to bear a definite relationship to the disease process. fail to Later they mist ake pers ons and objects. Allgemeine zeitschr. lasting for some time. sions. which lesions are usually combined. way The dreamy conduct of the patients often leads to the belief that they are in a constant state of intoxication.

several times a day where they are.DEMENTIA PARALYTICA dition of stages. A patient may say that it is summer while looking out upon a snow-covered field and with his hands resting upon a hot radiator. they have forgotten the first. when they had breakfast. the patients failing to record the time of the occurrence of events. or how long they have been in the institution. 213 me ntal to rpor is quite characteristic of the early These patients may answer questions quite corand upon superficial examination seem to conduct themselves in accord with their environment. or where If they walked the evening before. the The patients cannot times times tell what they did" several days previously. asked to figure five they reckon correctly five times ten. J The disturbance for the profound of apprehension is partially responsible is de fect of mem ory. but on the other hand a few may present hallucinations of all the senses a short time. one of the At first. with whom they are speaking. They cannot inform you when the mail arrived. This condition later reaches o ne of absol ute disorientation. and five five. which most prominent of the mental symptoms. but when they attempt to add the results. memory becomes defective for recent events. when the patients cannot perceive or elabo- rate any external impressions. Some of the pa- tients live so completely in the present that tbey may ask how long they have . The memory is especially defective in the ti me elem ent. fifteen. nor the significance of what is taking rectly place about them. but at the same time they neither know where they are. They fail to recognize the season or the time of day by the means close at hand. In the greater number of cases none appear. Hallucinations play an unimportant part. (TIallucinations of for sight are usual in patients with optic atrophy.

seizures. which finally leads to a complete destruction of all the mental possessions. . . and he escaped only by chance he led the troops at San Juan yesterday he had a conference with the British Ambassador invented an airship in which he has travelled to China. the patients being able to tell of occupation. 214 FORMS OF MENTAL DISEASE if been in the institution. and the most frequented is paths of thought are retained longest. or before. in which a dozen were killed. place in the intellectual life real often As memory fails. Lapses of memory. and the child- hood. made good by the As remi niscence s^ disappear. The rapidity of this process varies with the \intensi ty of the disease and the po wer of resistance. who complain it. imagination. the" former place of residence. ease. He captured a hundred . and imporcompletely forgotten. or the place of birth. Dates of marriage. patient was in a terrible railroad accident last night. as well as the intelligence of the individual. birth of children. pletely forgotten. This remote memory also suffers late in the disis and here also the time element the first to be affected. . invention runs riot. or what may have been said by a fellowThe patient. A married woman when often forgets her periods are comepilepti- maiden name. are now a part of their own experience. The more its intelligent resist longer. of and sometimes devise means correcting The early events of life are comparatively well retained their for a long time. the children. Whatever enters the mind is related as genuine stories. Finally they are tant events are unable to recall the names of the father.. occur most frequently following form or apoplectiform The store of ideas undergoes a progressive impoverishment. This defect is often keenly appreciated they have ever seen you bv the for patients.

DEMENTIA PAEALYTIOA beautiful 215 women from a Turkish harem. exhibit a feelin g of well be ing they claim that they never stronger or enjoyed better mental vigor. not unusual at the onset for the patients to express their It is some insight into mental disease. but in most the delusions form a prominent feature in the first dream world. genuine insight disappears. patients. Weighty obstacles are overlooked and senseless schemes produced with perfect serenity. their failing memory. In some there are but few delusions. The former conservative principles which have made their business life a success are lost sight of. so that they come to live in a sort which everything depends upon their The formation of delusions. but at the next visit all doubt will have disappeared. and new plans lack unity and system. of . Of these. the patient may at first be a little doubtful. These dream-like fabrications can lead to the greatest absurdities following suggestions from the listener. all Later. the and the increasing on the con- difficulty of thought. which is now bringing him millions of money. in own ideas and wishes. Objects of former criticism now fail to arouse comment. varies very much in different cases. Impairment of judgment is another very prominent symptom. complaining of irritabihty. Business and social standards are completely disregarded. felt The . trary. but centre almost entirely about themselves. but even then fail to recognize the real symptoms of the disease. Their conceptions have no bearing upon the environment. invented a new and inexpensive motive power for the automobile. with increasing deterioration. which in part arises as the result of this defect of judgment. At times during the course of the disease the patients may make they various hypochondriacal complaints. It m ay be the first to call attention to the disease.

IJjater the emotional tone becomes very unstable. exclaimed. pleasure in reading or professional pursuits. without ^ system and show confusion_and_incoherence. unstable. are sulle_n^_p£eyish. are indifferent to immoral surroundings. that he had no blood and could not breathe. At The patients are easily first there is usually irrit ability. numerous variations and contradictions. . " I am feeling fine come and see me again. there may be noticed an unusual insensiness. and apt to show considerable passion at trifling annoyance. the former . where there may be only a few delusions. and do not take the wonted tion . disturbed at home and work. On the other hand. the patients being in a condition of simple joy or irritable dissatisfaction most of the time. In the midst of laughter they in a storm of tears. in which they completely lose control of themselves.216 stage of FORMS OF MENTAL DISEASE the disease. bility to the claims of others. there is no especial . A patient lying on the floor. when tickled in the ribs and asked how he felt. or misery may give may break out way to silly hap- These changes of emotion may be brought about by simple suggestions or by raising or lowering the tone of voice. beginning to laugh. tone to the emotions. The emo tional attitude is much ter of the delusions . They are characterized by vagaries senseless. complaining that he had lost all his organs. indicative of the deteriora- of the finer feelings the pat ients jail to show sympathy at the suffering of their children. These delusions are tr ansito ry. The emotional life shows a profound disturbance. in acco rd with the charac- it is elated with expansive or dejected with depressing delusions. or by the expression of the face. and there are frequent and abrupt changes} piness. There is a profound change of disposition ." In the demented forms of the disease.

When reason for such conduct. Physical Symptoms. Any impulse that arises may be acted upon without reference to the extreme difficulty of its accomplishment.DEMENTIA PAEALYTICA stability 217 sive and independence of action gives way to progresweakness of the will power. In conduct the patients show a disregard for the demands of custom and law. in both the — The physical motor and the sensory fields. negativism. verbigeration. imposed upon one by the envisocial restraints normally ronment never interfere with the carrying out. A patient about to leap from a third-story window because of fear. frequently than in that condition. they may be easily influenced to desist by a simple suggestion. are as extensive . such as catalepsy. and occasionally injure themselves severely in In conditions of great clouding their foolhardy actions. so because it safety. and stereotyped movements. of the They are qu ite rec kless of personal patients' purposes. The patients become very tractable. and often commit grave offences into which they have no insight. are u nconstra ined. was readily prevented by the suggestion that it would be better to go down and jump up. of consciousness or in advanced deterioration there are sometimes present some symptoms characteristic of the catatonic form of dementia praecox. sorts of excesses may be excessively stuball Early in the disease they are led to indulge in and sometimes persuaded to deed away angered and determined to commit an assault upon some one. but occasionally born. As a property. One patient is said to have stepped out from the second-story window for the purpose of picking up a cigar stump. but The se are tr ansitory and change more_ readily and signs of the disease. they often say that they acted The happened to come into their minds.

It is noticeable in many cases . the patients may pull out an open wound. loss of consciousness. later analges ia appears. Of the se?isory symptoms he adache is often the first to appear. Some patients have difficulty in the recognition localization of objects held before them. In the severer forms. The special senses at first give evidence of excitation. which begin with a fall to the floor. corresponding closely in degree to the stage of deterioration. occurring in about sixty per p.ent. An attack of this sort is often the first symptom to call attention to the disease. there are all sorts of in definite pains. which may be either of the Jacksonian or of the type. The epileptiform attacks may be very light. is ascribed to involvement of and which by Fuerstner the occipital cortex. Of the motor symptoms paralytic attacks. These may appear either before the mental symptoms or not until dementia has become well advanced usually they are coincident. essential confusion or stupidity may usher in the attacks. Optic atrophy is found in at first ve to twelve pe r cent. draw out their toe-nails. Hemifi anopsia occasionally follows apoplectiform or epileptiform attacks.218 FORMS OF MENTAL DISEASE and profound as the psychical. and convulsive movements usually in one limb extending gradually to the others. of the cases. consisting only of a transitory dizziness with perhaps~an inability to speak. Finally. together with ringing in th e ears and d izzine ss. which later gives way to a state of insensibility. disturb tiform or apoplectiform. which may be so pronounced that nee dles can be thrust entirely through the limb withojifc__pain. were being held in a vice. of cases. are very important. and persist in mangling their own flesh. is The disturbance of the cutaneous sensations quite often prominent. either epileptheir hair. accompanied by a feeling of pressure as if the head .

hemiplegia. and may be the is first important sign of the disease. Other somewhat similar attacks occurring in the course of the disease are those in which there is a sudden development of extreme confusion. leaving the patient in his former state. diffi- and body. or hemianopsia. The frequency of the apoplectiform and epileptiform attacks depends somewhat upon the character of the treat- . Transitory sensory disturbances can similarly appear as paresthe sias. or defects of vision. anaesthesias. In the earlier stages of the psychosis. flushin gs oT the fa ce veins of the face. Con- movements may be confined to a single group of muscles or to one limb. more profound deterioand sometimes with evidences of transient aphasia. The duration of the attack is from one to several hours. cult s peech . with accompanied by is hemiplegia and aphasia. vomiting. may persist for days.DEMENTIA PARALYTICA that the vulsive 219 movem ents are synchr onous with the pulse. Apoplectiform attacks often occur. The attacks pass off slowly. A condition similar to status epilepticus. distention of the and rise of te mperature which may be excessive (one hundred to one hundred and seven These last from a few hours to a few days and degrees). sometimes leaving the patient in a condition of confusion. In some attacks there no loss of consciousnessTsmiply the siidden appearance of paralysis. often terminating in death. It is a distinguishing feature of these apoplectiform attacks that the paral ysis disappears qu ickly and without evident residuals. occasional high elevation of In these attacks there t empera ture. where there are to one from twenty hundred attacks daily. but sometimes clonic movements of varying intensity continue in one or more limbs for days. pass away quickly. the usual loss of conscio usness and stertorous breathing. these attacks leave the patients in a condition of ration. with motor restlessne ss.

220 FORMS OF MENTAL DISEASE They may from emotional d isturbances. There is also a loss of control of these muscles. Differences of the pupil occur in about fi fty-seven cent. They are also m ost fretransi- quent in the de mented form. . of the cases. sionless character of the tone. A fine tre mor of these muscles is almost always present. is ^conIn advanced cases there is often a rolling of the tongue about the mouth as if it were a quid This in some cases has been explained by the presence of areas of st ant sign. Lack of tone in the muscular system is also seen in their slouching and inel astic att itude. and the counte- This washed out.. The musclejLofjthe JacaJo^e__fchjdr nance becomes expressionless. which { may and retractive. Motor disturbances of the eye include occasional plegia. also complete opthalmo- and nystagmus. giving rise to incoo rdination noticeable mostly when the mouth or eyes are forcibly opened. single or double _ptosis. in the rectum. first Changes in the v oice often_are the appear physical signs to among singers. immobile pupils in about thirty-four pe r reaction to light in thirty-five and sluggish and five-tenths per cent. excesses in eating . and especially as apt to develop these attacks. aphasia and . the naso-labial fold and other lines of expression disappear. They are two kinds. p er cent. be present alone. The voice loses its characteristic tone. be either finely fibrillary or coarse anaesthesia of the mucous membrane. tory paralysis of single muscles. Gritting of the tggih is occasionally associated with these movements of the tongue or may Disturbances of speech are istic among of the most character- symptoms. an accumulation of feces Cases with prolonged rest in bed are not result ment. Tremor of the tongue. becoming monotonous. expresis countenance well represented by the group of three paretics seen in Plate 6.

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Speech disturbances more readily observed test words and phrases. as electricicity. The disturbance lytic of articulation may appear after para- attacks. There may be an elision of syllables. Defects in speech . Word blindness and word deafness are rarely encountered^ There is occasionally agrammatism. syllables are poorly united. should be introduced into if long sentences. as seen in the misuse of infinitives and omission of conjunctions. The used. ninth riding etc. if are in ordinary conversation. as in the use of elexity for electricity. in their efforts to overcome these sivespeech. indistinct. the attention is concentrated correctly. These difficulties lead to the substitution of words or syllables similar in Gliding over the syllables gives . difficulties. acteristic jdurring sound but more easily pronounced. as Massachusetts-etts-etts-etts. after p araattacks and is transito ry. movement of the lips making the speech rise to a charFrequent pauses are made between syllables or words. As the result of difficulty in and tongue. for this purpose are electricity methodist episcopal. and finally there may be tendency to repeat__syllables forming a genuine_wjiid_clonus. Massachusetts artillery brigade. but more often occurs independently of them. which may appear at the same time. elision of diffi- Many The of the patients. and when accompanied by a fall in the tone of voice produce a scanning speech. is more persistent and sometimes la sts several mo nths. or the cult syllables. upon single words they may be pronounced Words and phrases used national intelligency. but are ready to explain that these are due to dryness of the mouth or loss of teeth.DEMENTIA PARALYTICA defective articulation. because. Paraphasia. stutte r and produce an explo- patients often appreciate the difficulties oTspeech. or a reduplic ation of syllables. lytic 221 Aphasia appears onl y.

and may be spastic where there is involvement of the lateral columns of the cord. Later the more delicate movements in locomotion. of the cases aricTare absent in about twenty-five per cent. The Romberg symptom appears in involvement of the post erior col umns. In") fact. is characterized by irre gular ities caused by the tremor. Contrac tures and musc ular at rjEphy may appear late in the course of the disease. The tendon re flexes are exagger ated in sev enty per cent. who In advanced words and syllables. and many even give up without making a sign. patients are then able to make but a few unintelligible marks. The loss of patellar reflex is usually assoclatecTwith immo- . The irregularities are more extensive than in the may The handwriting case of the senile. Atax ia is less p rominent and appears first of all in those finer movements such as are employed by skilled workmen. tof which condition the name of asce nding paresis has beeny given. The clothing cannot be readily buttoned. which may be marked enough to simulate Huntington's chorea. Patients. excessiv e pressure on the pen. but they are proportionately more promi/nent (Plates 7 and 8 and fig.222 FORMS OF MENTAL DISEASE also be elicited by asking the patients to read aloud. whose lines show the effect of a fine regular tremor. such as turning about quickly. and in a few cases choreiform mov ements. ( telligible muddle of The \ases there is c omplete agraphia (figs. sway ing and shuffling. become affected. on the other speak clearly may produce on paper an unin/ hand. Intention tremor may be present. (Voluntary writing usually sh ows defects similar to those noticed in speech. 3 and 4). it is not uncommon to see cases of tabes dorsalis/ develop into paresis after a duration of some years. and carelessness. 2). the gait is unste ady. Fi nally all move- ments become ataxic.

substitution of letters and to write from dictation. in which the patients. " Around the Figs. simply laid the pen down. 3 Fio. 3 rugged rock the ragged rascal ran. 4 Fig. . after an attempt to write." and i represent conditions which approach complete agraphia. The patient has attempted the excessive pressure elision. besides syllables.Ron Fia. 2 Fig. 2 shows.

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The vasomotor disturbances s kin. and othe mato ma are of frequent occurrence. so to that a very trifling injury may lead an extensive to heal. and der- mographia . there may be a short period of a few hours or more of an excessively high temperature without apparent adequate cause. acute decubitus. . the the former.DEMENTIA PAKALYTIOA bile pupils 223 and myosis. distention of the bladder. lesion. which often leads to fatal outcome. persistent blus hing of the rush of blo od to the h ead. but in the last stage the patients are sluggisn^and~ may sleep much of the time. is latter usually being the result of Sluggishness of the bowels may extend to Finally in the end stages there paralysis of both sphincters. when it is apt to be subnorm al. pneu- monia. obstinate constipation. which contains the trophic fibres for the lungs. especially the first. such as mildj bronchitis. A peculiarity is the excessive elevation! of temperature with trifling disturbances. except toward the end. The first sleep is usually somewhat di sturb ed during the stagehand more so d uring the sec ond. The so-called trophic changes. is regarded as a disturbance of the vagus nerve. Dis- turbances of the bladder are often present. This varies. there is a loss of vitality and of the power of repair in all tissues. increased fragil ity of the ribs. Acute decubitus once started is difficult The te mper ature during the course of the disease is mostly normal. Furthermore. or constipation^ There is often a rise of temperature during a paralytic attack. the however. but later it is diminish ed. and finally. consist er ythema . both retention and incontinence. where there is motor excitement. as in some cases the patients may from . as mentioned before. By some. The of s exual power may be inc reased at the onset. increased at The fi rst. electrical irritability of the muscles is but later diminishe d.

varies widely in different cases. Sometimes loss of appetite and impaired nutrition coexist. as the proto- which has been and less still is by some regarded type of the disease. of cases. when usually a greatjnereas e in weight. Other evidences of the profound disturbance of metabolism occurring in dementia paralytica are the presence of albumen and suga r hi the uxine and fall of the percentage ot he moglobin The mental symptoms enumerated above represent in . The deviations from these types deter many from the of . The clinical picture of megalomania. unaccom panied by many delusions and hallu cinat ions and its . because . while in other cases in somn ia persists throughout the whole course. has in recent years become less and prominent. This has led to the recognition of four types of cases de mented expansive. leading to extreme emaciation. of its great predominance. should be regarded as_thejype of the disease. each which presents a somewhat different course from the onset. until it is now encountered in less than twenty-five per cent. which may last until death. p oor unt il and during excitement. The dem ented f orm. ag itate d. The grouping of the individ- ual symptoms. however. general the clinical picture. and depres sive.: 224 FORMS OF MENTAL DISEASE onset show a tendency to sleep continually. rapid course without remissions. but its value becomes apparent in a considerable number of cases where one is able to forecast the future duration of the disease and the character of many of the symptoms. . but The condition of nutrition excitement subsides and deterioration is well there is advanced. The is appetite suffers at first later th e patients e at well. the acceptance of this differentiation. and its simple character with det erioration.

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and irritability. or periods of megalomania. failur e of me mory. lose account of time. make mistakes in figures. feeling of pressure in the head. delusional states. . is 225 characterized by gradually pro- gressive mental deterioration without delusions. and they occasionally fall asleep over it. are easily led astray. and often drink to intoxication. Soon disturbance of apprehension appears. but all of these are insignificant when compared with the rapid advance of profound deterioration. and is absence of the usual moral feeli ngs. depression. in errors_of_juiigment. or great prominence of either psycho-motor disturbdeliri- There may be frequent transitory periods of ous excitement. In some cases. however. may resemble those of neurasthenia patients loss of complain of inability to apply themselves to work. Their work irk- some. They are forgetful and flighty. The household suffers. indefinite pains. energy. They forget to go to meals. when the patients fail to compre- hend thoroughly their environment. The onset at first of this form is very gradual. they become obstinate and self-willed. The symptoms . Patients are reckless and may even act in opposition to established precepts. and the children are neglected. and overlook important matters. Soon mental deteriora- tion becomes apparent in the inability to explain their actions. but have a clear insight into this condition.DEMENTIA PAKALYTICA Demented Form The demented form hallucinations. tractable. and mistake persons. They are usually good-natured. In conversation the thought is sluggish and lacks individuality. ance. anxious unrest with hypochondriacal ideas. dinner is uncooked or improperly seasoned. get confused as to place. and at others somewhat confused. at times drowsy.

rebuffing friendly advances and opposing without reason anything desired of them. and surly. when the patients complain of slowness of thought and failure of memory. drink. The capaci ty become letters to work ver y soon suffers. They may become and wander- ing restlessly about. of On the other hand. answering questions as if angry. They lackjwilL power. Sudden changes of emotion are more prominent at first. . greet strangers very cordially. indulge in excesses or commit petty crimes. forget when to go to meals. They are perfectly contented wherever placed. The all patients careless in their duties. such as food. are unable to care for themselves. when the feelings are by suggestion but later the patients become uniformly dull and ap athetic. Occasionally there are weak attempts at fabr icati on. and tobacco. It sometimes happens that they struggle along with their work.226 FOEMS OF MENTAL DISEASE this time a few delusions may appear. sometimes with hallucinations of The delusions are very_ weak c hildi sh. realizing and worryfinally stay ing over difficulties and frequent errors. Others neglect restless. forget engagements. either depressive or expansive. their occupation to look after all sorts of unnecessary unprofitable affairs. and neglect their personal appearance. repulsive. At . but the later increasing deterioration obscures this feeble capacity. Often at first there is some insight. easily influenced by suggestion. easily influenced . some patients are inaccessible. and hearing. they may express a feeling well-being and perfect confidence of their business for capacity. are easily led astray. and away altogether. go to work at hours. allow go unanswered. and are very friendly with every one. have a complacent smile when addressed. On the contrary. as long as the simplest needs They are satisfied.

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periods of ex- citement. The duration is rather shorter. quite sudden. Occasionally The patients develop a marked feeling of well-being. and present the picture of health. They busy themselves with new and elaborate schemes for getting wealthy. The mental deterioration may have bee n'so gradual and so unobtru sive that the f riends and relatives fail to appreciate the profound degree patients. of casesjiying within six months. one-half of the cases. and appear perfectly at ease in talking about themselves.DEMENTIA PARALYTICA 227 an advanced stage of deterioration. and are unable to give any coherent account of their lives. and a few living^veTthree years. and transitory speech disturbances are often the first symptoms is to attract attention. and energetic. talkative. in spite of A few of deterioration exhibited. is sive delusions. affable. Paralytic attacks occur in almost Remissions are less frequent than Expansive Form This form remissions. in the other forms. of the cases. and draw designs for . and signs of failing memFainting spells. they are bright. with change of character. present a_good demeanor. They greet one correctly. although the disease may have the onset been in progress for some time. and greater prevalence of The onset difficulty of is usually gradual. mental application. sleep w ell. seven- teen per cent. but at the same time are disoriented. characterized by great prominence of expana prolonged course. stake out property. The patients usually enjoy a good_appetite. This form of dementia paralytica embrac es forty per cent. short ory and judgment.

regular business. Business is flourishing . . but now run the fastest and finest train in the world. whip the best man on can lift tons. ordering large quanof material for building and for other purposes. allowing none but millionaires to ride besides a profitable law business. The patients claim never to have felt better in their lives. book can compose beautiful poems can deliver an oraThey associate only with the most tion on any subject. . because of its They have the inspiration to write a excellent qualities.228 FORMS OF MENTAL DISEASE They are busy from early wonderful machines. Tbe numerous expansive delusions at first are within the range of possibility and may appear attractive to the unsuspecting. . they are now engaged in writing a novel which will startle the world. from New York to Chicago without a single stop. their voice is clear and and can be heard for many blocks. only the genuine blue blood courses through their veins. they have secured rich gold claims in Alaska. and still there is more work than they can attend to besides their . they are making a " mint of money. but soon pass into imagination. tities morning to late at night. earth. . with the picture of restlessness. acteristic the realm of absurd of the prattle of much and presenting. can have the strength of a they speak as thousand horses. fluently several other languages distinct . They believe their English the best." have several gangs of men working for them. which are doubling Formerly they were brakemen. reminding one very children. they are going to build a marble mansion at Newport. chickens are being raised by a special improvised method at an enormous profit in wealth daily. and have a floating palace. and can move a train. cultured people . . the char- megalomania. soliciting patronage.

and will reconstruct the system of the world. to extend over the whole earth. and for this reason he was appointed detective of a marine insurance company. He now has formed a chicken trust Paris. which encircles the globe every twenty-four hours. social whose eyes are diamonds. and had under her five hundred girls. A jockey had discovered a new way of breeding and training runners. and London. and each . whose feet are gold. now drives the largest engme in the world. The patient the product of a more dreamy ingenuity.DEMENTIA PARALYTICA and for 229 which they have received priceless offers from publishers in this country and in Europe. which had won her world-wide fame. having been called to all of the courts of Europe because of her wonderful success. and had travelled all over the world inspecting vessels. drawing a thousand palace cars. She herself could cut and sew a hundred dresses a day. so that only the Chinese will Another has a most be employed in hatching the eggs. The abound in contradictions and become more incoheren t. and now from his Kentucky ranch was supplying every circuit and handicap in a vessel wood with winners. A ship car- penter developed wonderful power in his eyes. wonderful herd of cattle. San Francisco. stopping only at New York. He had become so wealthy that all the banks in the state were in his possession. She could sew on a thousand buttons a minute. A seamstress had devised a new method for cutting dresses. all of whom used golden thread. all lined with gold and trimmed with pearls. The are utter absurdities which increase from of day to day delusio ns proof the increasing weakness. whose horns are forty feet high. Calcutta. so that he could detect defective by simply standing in the hold and looking outward.

have sent Christ to Mars whatever they touch are the greatest turns to gold. and each would have to go two times in order to bring away the silks and diamonds. In women the tendency to expansiveness . and that he would farms cross the ocean and blow up all of the countries and bring the people out west and put . The patients are the most beautiful beings that ever They have married seven hundred millionaires. all sciences. which are filled with the most glaring contradictions. are not human but divine. They slippers . . lived. mond trimmings . They know . the best the choicest wines and Havana cigars will be supplied . may change These delusions are almost entu£ely_sel£*©»fcred. have twenty thousand children. the patient himself milking a thousand a day. and there will be a dissecting room. one million marines. that he wanted six thousand billion . physicians in existence will build a hospital of marble twenty Avhere stories high. where ten thousand bodies can be kept the time. gun-boats. can create a universe. visit all the stars. and that he would give each one of the marines two bags. provided with a bar for the doctors. They will build a tunnel through the earth and bring all the Chinamen here to work. all of whom have gold cow produces and gold dresses they themselves wear only diathey can fly away in the air to a world where there is a castle ten thousand miles long filled with lovely people who do nothing but amuse themselves. They rapidly. One patient said that he was going to build towns that he had been to Washington to see the President. one million bomb-shell boats. each day new and more""extravagant ideas appearing. with all a huge ice box. them on that he would blow up the Queen's buildings.230 FORMS OF MENTAL DISEASE five hundred pails of milk in twenty-four hours.

The patients are too much absorbed in their numerous ideas to note the surroundings or to take account of time. is may and sometimes flight of ideas. education. theft. This and assault and battery. and perjury. What a glorious century never forgotten. dis- psycho-motor restlessness. there tractibility. can be that N year has been a became a Christian the last of the year. Billy became a ! — . The tortures of the Spanish Inquisition have been found to be the greatest elixir for the health of those whose only relief to that time had been the Our laws have been changed tender arms of our Saviour. Consciousness becomes some what clouded after the development of the delusions. whose very presence is a panacea. day. violence. or the year. would have come far short in the greatest desideratum on earth or the whole universe.o DEMENTIA PARALYTICA is less 231 marked. Later they become acquainted with the place and a few of the persons. The content of thought is centred entirely about se lf and the many varied delusions. and but for a fortunate accident the men of science. culture and God-like Christianity. Hallucinations are rarely encountered and never take a very prominent part in the disease picture. and may produce a continuous stream is of delusions. and may be from the onset. especially where it is subacute. although at times. in connection with great be incoherence. There is usually disorientation as to place and persons. The patient usually talkative. and women of gazelle: " tury has like charms. deceptions of every conceivable manners of conveyance of information have been cut off. the following being a sample — Dear Billy The early part of the twentieth cenmade wonderful strides from its start. but they rarely know the month. Incoherence of thought more evident in : their letters. At first it is usually coherent.

Irrit ability is always present." bed. agreements or doubts attack. remaining up until late at night. and are associated with the finest men in the world. or weep because of harassing persecutions. have the best of food. they are in luxurious quarters. relative to their superiority or immense wealth may arouse anger or even an aggressive Later in the course of the disease this disappears. many letters. Grandior malum grandior bonum. Dis- manifesting itself upon the slightest provocation. fine clothing. It often happens that for a short time. travelling about from They are very_talkative and make con- fidants of every one they meet. fast horses. when asked how he on his deathoften says with some ani- A paretic mation. attitude corresponds closely to the content the patients are cheerf^Jmppy^liopeful. At first the patients are restless bustling about on new and important business. and be come dep ressed. writing place to place. devising plans. and expressing hypochondriacal delusions. and even contractures. paralysis. fine. a few <tl they lose spirits I moments or hours. It FORMS OF MENTAL DISEASE would have been a case for those scientific men to make a study of unheard tortures to cure this. co ntente d. showing the great instability of the emotional condition. fine. Everything in the environment is pleas- ing . plenty of servants. . complaining of confinement. exalted. " The psycho-motor condition exhibits more or less excitement from the onset and may reach an extreme degree. leaving the patients in a uniform state of quiet cheerfulness in spite of their bedridden condition with filthiness." The emotional of the delusions . it is Hjitterly Even when to reestablish most miserable possible by suggestions the feeling of well-being. rarely days.232 Christian. For short periods in the develop extreme_j£ailess- course of the disease they may . feels.

aggr essive ness. ana" unpuTsaK^essT They shout from fear. and show a lack of judgment and mor al obtu seness. but every action shows an absence of plan. They may assault or commit thefts. seek the company of lascivious women. In actions the patients soon become foolish. 233 with insomnia. recklessness. mutilate their blindly diving into own bodies." "beautiful women. disappearing gradually. the activity production of unintelligible letters and plans. complete clouding of conscio usness. of the paretics.' fiftee n to is simulating the picture of manic-depressive insanity. invariably asserting with brightening countenance that they are feeling fine. " millions." "fine horses. and the duration sixte en less than one-third of the cases dying within more prolonged. . The expansive form comprises from per cent. that the exp ansive form passes over into the d epress ive. It is and rush about impossible to any obstacle. and become disorderly in dress and careless in appearance." — ( mere relics of former ideas which life. scribbling on paper. The patients are happy and contented throughout it all. and utter disregard for leave the patient in a state of : others. two y ears. and this may take place several times. They develop bad habits smoke or swear. They may be heard mumbling to themselves. attract their attention or to get coherent answers." "grand mansions. fight off They imaginary enemies and shout threats and curses. limited to the denied with perfect serenity. it is all When confronted with their observed behavior. now It represent the last traces of their intellectual sometimes happens. and vice versa. and collecting useless rubbish. is As the disease advances. These conditions of excitement rarely last longer than a few hours or days. enjoy telling obscene stories.DEMENTIA PAEALYTICA ness. and usually more profound deterioration. recklessness.

of the paretics. The world moves and stands at their command. They have acquired all knowledge. Remis- sions occur in one-th ird of the cases. have hell. They and by a new formula man shall be increased a hundred-fold in size and shall have a third eye. could carry an ocean vessel or fly to the moon in a second. more than any one man to create animals. Agitated Form by its relatively sudden onset ivith a condition of great motor excitement and the presence of the most extremely expansive delusions ^gr eat clouding of consciousness and a short course. The patients suddenly become very energetic. God and the universe have a new method of been everywhere from the heights of heaven to the depths of They are now establishing reckoning time. language. created They themselves are God. teaching them . Their wealth is fabulous. and the years ten thousand months. They are interested in all wars and have marshalled huge armies. expressing a pronounced feeling of w ell-being.234 FORMS OF MENTAL DISEASE fifte en A few cases extend through s even to years. It represents a special group of the expansive form and It may constitutes about _tgn per cent. All great battles have been won by them. know how . to known God over God. is A change of disposition often noticed for a time previous to the sudden out- break. This form is characterized usher in the disease process. and the weeks are to contain one thousand days. possess the ambition and the strength of ten thousand men . presenting great similarity to the picture of delir ium tre mens. by their decree the days are to be one thousand hours long. can educate a thousand speak every men an hour. They are born again.

seem even to surpass the bounds of imaginaof pure gold. ten thousand billions houses acres . they own . with gilded domes set with diamonds are of onyx. ten thousand billion cows land. ten thousand billion ten thousand billion built . untold misery from sharp pains in the back some one entered the room at night and disembowelled them. trimmed with sapphires. etc. and tion. and prattle . may be present. 235 All quantities are reckoned in the . through which elec- trical currents are nightly applied. sing. but ar e not pro minent. Sometimes stupidity for allowing they are perplexed at their to own themselves to be confined in a hospital instead of going Europe to consummate a deal by which millions would Hallucination s of sight and hearing have been made. of Their houses are of Italian marble. limbs and completely burn. laugh.DEMENTIA PAEALYTICA ever possessed before. about the . showing The patients are talkative. all furniture is the floors ings are of the finest fabric. finally and the hangpearls and Their ideas become more and more expansive. Very ideas often they give expression to a few pessimistic : which may be hypochond riacal they are suffering . and occasional impulsiye_jnjjveinents. but at the same time one is assured that they are undergoing a process of purification which will leave them healthier and mightier. which leads them momentarily to fear that they are suffering from cancer of the most malignant type. causing the flesh to There may be some insight into the failing mem- ory and the defective nutrition. filling the skull. The psychomotor great restl essness condition is much disturbed. failing to influence the clinical picture to any extent. so that the following morning they could not go to stool miles of fine electric wires have been placed in the flesh. shout.

The temperature may b e subn ormal. issuing commands to military staffs. There to a marked irr itabil ity. scribbling unintelligible letters to millionaire friends. and sending They have cablegrams to the different crowned heads. The restlessness being in constant .236 FORMS OF MENTAL DISEASE like children over their innumerable plans and many They are co nstantly_j ri mo tion. interference quickly leading threats. neglect personal appearance. unable to comprehend the surroundings or to respond to questions. and expose themselves indecently. no care for themselves. working in a planless way on vari- away ous schemes. producing titions They are noisy. ing. This condition sometimes represents the end stage of the agitated or of the depressed form. The emotional and there attitude is usually one of great exhilaration. masturbate. going from pleasures. because of the small amount of food ingested and great restlessness. the patients many repe- of syllables is or purely inarticulate sounds. Physically." in which there is a rapidly fatal course with a clinical picture very similar to that of an " Acute Delirium. and ag- gressiveness. with extreme. the condition of nutrition is a great loss__o|_weight. shouting and sing- an unintelligible babble. The patients are completely confused. with cursing. leading in a few weeks or months to fatal collapse. forget about eating. The ideas. association of ideas is somewhat incoherent. often with a flight of It centres entirely is about themselves and their plans. passing rapidly from one idea to another. smear their dresses or the walls with the food placed before them. an outburst of passion. one thing to another. suffers profoundly. few cases of the agitated form may be characterized as the " galloping variety." These cases present an ext reme grade A of excitement and profound clouding of consciousness.

DEMENTIA PARALYTICA 237 motion. this condition is primarily diagnosticated and treated as neurasthenia. which with heart failure lead to death. the numerous pains. and The mind becomes centred of application. . their de creasing power upon exertion. the mouth with sordes. and bruising themselves extensively by their reckless movements. attacks are frequent. upon their condition and they become despondent over it. that they can never recover. The onset of the disease in this form is insidio us. i The temis filled perature becomes elevated as the result of nfectio n the various wounds or acute decubitus. thirds of the cases is Paralytic The duration less in more than two- than two ye ars. in which from the movements are uncertain and tremulous. their greater wearine ss their change of di sposit ion. They soon become hypochondria cal. profus e perspiration and diarrhoea appear. and that they are Very often suffering from a complication of diseases. Depressed Form of the emotional attitude and of the delusions throughout the whole is This form characterized by the depressed tone course of the disease. The persistent headaches. The weig ht falls ra pidly. Remissions occur in one-fourth of th e cases. the temperature becomes slightly elevat ed. claim that they are syphilitic. slapping their hands. The patients notice their f ailing mem ory. After a few weeks or months the restlessness subsides into a condition of stupor. waltzing to and fro. attacks are frequent. and the heart's action f eeble and irre gular Epileptiform and ap oplectiform . pounding the bed or wall. forcing the legs up and down. running about the room. and failing memory lead them to consult one physician after another.

The have dried up. or may if would fall apart lie abed as moved. They have caused the death of a and every one knows that they are that they have always been murderers. and their manhood has disappeared. expect- . the stomach melted away. and they have turned to stone. and the intestines are so paralyzed that there has been an accumuthe lation of excrement within them for many months. patients believe themselves great sinners. a false passage has formed so that the " vital fluid " passes out of the rectum. friend by negligence. They may sit for hours with hands on their throat for fear feces will pass into the mouth. A patient moaned for months because he had not provided his family with suffi- and was being held up to the whole world as an example and must suffer the penalty of death. because they are being constantly watched. cially the face In connection with these ideas they are constantly fingering different parts of the body. They persist impure and have led many astray. espe- and sexual organs. the blood has ceased to circulate. so that water passes directly through them. testicles They claim that they are dead. the skull is filling in with bone. claiming that they Delusions of self-accusation are usually associated with these hypochondriacal ideas and occasionally predominate in the clinical picture. rotting away. the of taste is lost. The cross. causing the brain to shrink. mouth is is filled with sores. so that food passes is up into the brain. that they have committed the unpardonable sin. kidneys have been moved. if dead. the sense the throat clogged up. and injured their children. must die on the have stolen property.238 FORMS OF MENTAL DISEASE Their hypochondriacal complaints sooner or later become They then complain that the scalp is entirely senseless. Very often in connection with these ideas of self-accusation they are cient food fearful.

At the table others are deprived of food on their account. on whose head The troops have been summoned to escort them into exile. Every unusual sound causes them and shrink back farther into their rooms. friends are mistaken. as "death. are and forth in their rooms. and refuse to enter the dining room or even leave their to shudder own rooms. are slandered by a crowd of consciousness soon becomes men outside. In this condition . to their The bathing of others suggests fellow-patients. There considerable disorientati on. lives. signifies minds that they have polluted their and the preparation for the morning walk that the whole company are getting ready to attend their public prosecution. with the head buried in the clothing. The patients listen to the reading of their own indictment. In this condition they may attempt suicide or mutilate their own bodies one patient . Hallucinations of hearing often accompany these vari- ous delusions. and is time confused. The is much clouded. tore through the anal sphincter into the vagina with her . sometheir times uttering single expressions." pick at their finger-nails. to leave the bed. moaning and groaning.DEMENTIA PARALYTICA ing at any 239 moment to be imprisoned or carried away to the scaffold. they develop great anxiety with restlessness pace back "destruchair. pull out unable to eat. Delusions of persecution self-accusations. Occurrences in the surroundings have reference only to themselves. Finally they cannot be persuaded because of intense fear. or overhear an intrigue against them." tion. but lie huddled up at one side. They there are being regarded as desperadoes a high price. may exist independently of the plots when they suspect against their and complain that is their families are being outraged.

years o f age. i The chief symptom is a coherent system of delusions of persecution with clear consciousness. infrequent repetitions. especially melancholia of Stuporous states appear at times. le ss They may be may show some be more or Hallucinations and illusions may pro minent or entirel y wanting during the stupor. which may last for several months. refusing nourishment and allowing the feces and urine to pass unheeded. and appears rather latein_Jife. lying abed in one position ous to the surroundings. of the cases. which simulate for a /time paranoia or the paranoid form of dementia pratcox. Although retaining many of is theysho w_ no emotion. which by the shorter duration serves from that found involution. very long at a time. restlessness does not exist hand. not always uniform. or inco heren ce in thought and weakness in manner is make The it evident that there a rapid deterioration process. perhaps resistive. In the interval the patients are quiet but despondent and seclusive. A few cases occur in this form. the delusions fail to form the basis for their actions. to differentiate this depressed condition and some humor. in other psychoses. as one The mental depression occasionally notices a feeling of well-being or indifference. and their judgment shows great weakness. the depressive delusions. patients adhere to the delusions less persistently. usually only for a few hours or a few days. emiss ions in this form are rare. After some months. a coherent train of thought. dementia paralytica comprises o ne-fourth of the cases.240 FORMS OF MENTAL DISEASE Extreme anxiety with. occurring in less than twelve per cent. when the patients are oblivi- mute. emotional at times. or anxiety. and even lachrymose. The depressive form of mostly after f orty R . and a normal emotional attitude. or perhaps a year. contradictions.

devoid of any prominent symptoms indicative of definite stages. Sensation greatly impaired. when the in symptoms remain abeyance for a few years. former They sit unoccupied save for the taking of nourishment. The lines of division are very indefinite. muscular atrophy and weak- ness become marked. The terminal stage is apt to be prolonged. 241 die within as the greater number ye ars. In it the patients are dull.DEMENTIA PAKALYTICA The course two is r ather s hort. and the Termi nal stag e of dementia. unable to care for themselves or of occasionally expressing incoherent fragments delusions. the in most frequently tion. Course. entirely indifferent to their surroundings. demented and the expansive forms. and finally contractures appear. The physical signs in the different stages vary considerably and stand in no definite relation to the mental symptoms appearing ing the latter. or follow- The two important are paralytic attacks factors in the course of the disease and remissions. being followed by a deterioration. — Dementia paralytica has been divided into three stages by of^Sc ute many writers: the stage of _onset. The attacks may appear at any time during the course. physical The symptoms is in this stage advance to general paresis of all of the muscles. or the case may be one of apathetic deterioration from the onset. producing an unexpected progress in deterioration or even a fatal terminain the disease. necessitating confinement in bed. before. stupid. They may usher . as the first stage may very quickly pass into the acute stage. apathetic. to which they often have to be helped. but more frequently advanced condition of These attacks appear occur during the terminal stage. In the end patients become nothing more than vegetating organisms. simultaneously with. the stage symp toms.

The improvement which is usually rapid. but in some cases it extends over clear . it is apparent to their friends that they have lost their former mental energy. Some of the patients are able to their former occupation engage successfully in and support their families. careless in personal appearance. physical and . and irritable and fretful in disposition. Both the mental symptoms show marked improvement the consciousness becomes clear. In is other cases the remission only partial. with a desire to enter into uncertain business ventures.242 FORMS OF MENTAL DISEASE Remissions are most often encountered in the agitated and expansive forms and very rarely in the demented forms. According to Siemerling ninety- . weakness of judgment. and are changed in disYet they are usually eager for employment and tire easily. they appear perfectly well. the patients be- and coherent. and the delusions and hallucinations disappear. In the course a month or two they may have so far improved that as far as limited associations of the institution permit. The duration of the remission seldom lasts over three or four months. change of moral character with greater pliancy in conduct. the content of thought coherent. of which defective pupillary reaction is the most prominent. disregard the advice of the physicians to exercise care. they position. and the physical symptoms. while the expansive and depressive delusions disappear but there still remains a tendency to excessive activity. The patients often look back upon their psychosis as a sort of of dream without a clear insight. Diagnosis. come three years. essential — In the diagnosis of dementia paralytica the symptoms are defective memory and attention. When at liberty. appears only during the earlier stages of the disease. emotional indifference. however. to be lavish with money.

moral instability. defective time orientation. silliness and incohe- rence of the delusions. The melancholiac shows a greater prominence of self-accusations and infrequent clouding of consciousness. inability to arrange syllables and words in proper order. while paretics often fail to recognize such of neurasthenia mental rassed. where the differentiation must depend almost entirely upon the presence of physical signs. alcoholism. and presence of physical signs. The disease is distinguished from neurasthenia by the absence of insight. of the disease is The depressive form ration. and diabetes can be excluded. The physical symptoms are confined to dizziness. which really does not exist. exaggerate their dition. uremia. Neurastheniacs appreciate too keenly their illness. and lack of improvement with simple relaxation. tremor of the tongue. and tremor of the are almost sure signs of the disease. distinguished from melancholia of involution by the presence of mental deterio- weakness of judgment.DEMENTIA PAEALYTICA two per cent. failure of memory. if epilepsy. point to dementia paralytica. immobile pupils belong to Defec- tive speecb with slurring. and at the same time try to alleviate then conThey complain of failing memory. symptoms. except in cases with great prominence of hallucinations and delusions. facial muscles. of 243 paretics. slight stammering when embar- and fine tendon life reflexes. failure to carry out medical advice. forms of manic-depressive insanity are distinguished by the absence of any signs of mental deterioration and by the presence of retardation among the depressive The . defect. The apoplectiform and epileptiform attacks without residual motor paralysis. with increase of the One should at least think of paresis when first neurasthenic symptoms appear for the time in middle without adequate cause.

244 FORMS OF MENTAL DISEASE motor phenomena. consciousness. and he less pliable. the presence of mannerisms catatonic forms by the stereotyped actions and speech. while the paretic is unable to comprehend his surroundings. less prominent clouding of and the consciousness. heed threatening attacks. The paretic is unable to recall correctly recent and especially the date of their occurrence. and dependent upon the The maniac. is more alert and quick in apprehending when his attention can be attracted. The paranoid forms do not show paretic inability to comprehend the surroundings. Dementia prwcox is differentiated by the absence of the characteristic physical signs.. The maniacal forms of manic-depressive insanity are differentiated from the expansive and agitated forms of paresis by the pressure of activity and the absence of mental fails to deterioration. sight and an absence of terrifying hallucinations of and hearing. require consider. In the stuporous states the manicdepressive patient partially apprehends his surroundings. delusions are less often contradictory. his events. are expressed with less assurance and more facetiousness. he shows an acute memory. and negativism. and contradictory his emotional attitude is variable. especially where early paretic symptoms have escaped notice in an In the paretic there is a profound clouding of alcoholic. voluntarily. and occasionally moves freely and even restlessly. on the other surroundings and suggestions. is seldom contented and It often happens that periods of excitement at the onset of the disease are mistaken for delirium tremens. although he takes no part in them he shows some anxiety and discomfort when interfered with and seldom moves . His delusions are more extreme. hand. fantastic. while the alcoholic presents the characteristic mixture of anxiety and humor. .

may be recognized by the age at onset. and the coherence in thought is well retained. the length of . can be distinguished from dementia paralytica only with difficulty. sometimes septicaemia following infection from wounds. sometimes suffocation caused by food entering the air passages but the usual manner of death is from . the disease later running a typical course of dementia paralytica. which persist for at least a few weeks. when not focal and when occurring later than ten years after the primary infection. the muscles atrophy. Death occurs in the vast majority of cases within two years . the only point of differentiation being the cupped optic bisc. Senile dementia. shows marked improvement under the influence of anti-syphilitic treatment. and life gradually flickers out. Cerebral lues. life. The patients become emaci- ated. the pulse becomes imperceptible. Cases of cerebral tumor occasionally run a typical course of the demented form of dementia paralytica. One case of eighteen years has been reported. however. varies in the different a few cases survive five or six years. The immediate causes of death are paralytic attacks. and intercurrent forms diseases. the more prolonged course. which is also due to extensive degeneration in the cortex. marasmus and heart failure. and are associated with very little mental deterioration. excepting partial paralysis and apoplectiform attacks. comparative poverty of delusions and absence of characteristic motor symptoms. the heart weakens. as the improvement may be only temporary.DEMENTIA PARALYTICA 245 able time for the delusions to equal in expansiveness those of paresis. Usually brain tumors give evidence of focal motor symptoms. It usually The prognosis of the disease is decidedly unfavorable. . pneumonia. but even this is not a sure sign. the last of which in senile dementia are usually followed by signs of motor paralysis.

In the whole pack a large and heavy woollen blanket is spread upon the mattress. and from one-half to two or more hours in duration. and numerous Next to rest. and the establishment uncomfortable ness and of a suitable routine in the physical and mental life. and over it is laid a coarse linen sheet. The administration of anti-syphilitic treatThe ment is more often detrimental than helpful. fashionable at procured a be cannot relaxation rest and health resort with the bath cures. and caretobacco. The partial results. and the open air. so placed that the patient can lie at the junction of the middle. follow its use to improvement claimed marked cases of only coincide with the average number of expected remiswhich there is no improvement. the cold packs may be substituted. while in many cases in prolonged warm baths. which in the hands of several American physicians seems to give excellent The packs to be effective must be properly applied. or to the arms. . abstinence from alcohol. with the removal from busisurroundings. pack usually suffices to bring about the desired result. but others require hospital treatment. the right portion of the sheet is drawn The arms are lowered to the side and covered across the body and tucked. fully executed hydrotherapy and light massage are of Moderate exercise in great value. When the patient is in position. and right third of the sheet. In conditions of excitement with extreme filthiness. The conditions of excitement are usually relieved by sions. well wrung out in water of a temperature from sixty to seventy degrees. massage. 1 Where the warm bath is inaccessible.246 FOKMS OF MENTAL DISEASE of the disease is The treatment first requisite purely symptomatic. deterioration seems to be more rapid and profound. applying it to the lower extremities. the being forced rest. coffee. given at a temperature of ninety- eight to one hundred degrees. Quiet and tractable patients in good circumstances may be treated Suitable at home. the patients 1 may be kept in the bath continuously for some days. nutritious diet. tea. there should be planned a attractions. with the arms elevated. and provided with a wet turban.

. especially about the neck and feet. It should be remembered in the application of these partial packs. and the body frequently cleaned with cold water and alcohol. and free from crumbs. Daily observation is of the condition of the bladder sary. rubber cloth or oil silk. clean.DEMENTIA PARALYTICA 247 The conditions of extreme anxious unrest with excitement seldom yield to any form of treatment. When the patient falls asleep in it. the former of which may given by subcutaneous injections in a five to ten per cent. one may try large subcutaneous injections (one and one-half pints) of normal salt solution. several woollen blankets. with the left portion of the sheet. clean. It is only liquid. means that bedby sores can be avoided. pack. Frequent changes of the position of the body prevent the occurrence of hypostatic pneumonia. solution. In the last stages of the disease. Acute decubitus. extreme cleanliness this is the essential requisite. which can be repeated twice daily for a week. once formed. and bowels be also neces- Finally. in order to prevent choking. If prolonged warm baths or cold packs fail. smooth. the mouth should kept thoroughly The paralytic attacks may yield to ice packs on be the head or to amylene hydrate (thirty to sixty minims) or chloral hydrate. which is drawn across the body and securely tucked. that all air must be excluded from in under the cover of woollen blankets. it is not necessary that it be removed There is no harm in an immediate renewal of the partial until he awakes. as well as in the whole packs. for which purpose many use a final covering of to one hour. is very obstinate and should be treated surgically The nourishment in this stage must be as an ulcer. The duration of the partial pack may be more extended than that of the whole pack. The bed-clothing must be kept dry. The patient is then covered with The duration of the pack should be from one-half and may be followed by brisk rubbing with alcohol.

Volkmanns klinische Vortraege. 161. Nothnagels specielle Pathologie u. Die progressive Paralyse der Irren. 1894. Krafft-Ebing. Bd. 1899. General Paralysis of the Insane.248 FORMS OF MENTAL DISEASE BIBLIOGRAPHY Voisin. 2. Therapie. 1880. 9. Mendel. 1886. . Mickle. Traite de la paralysie generale des alie"nes. Ilberg. 2d edition.

» irritability. Besides the diffuse sclerosis of the brain. a 8 Berlin. 249 . of demented same parents. the frontal lobes. 1894. hemiplegia. is extensive in and atrophy of nerve of neuroglia. 863. Psy. ebenda. and even symptoms.ORGANIC DEMENTIA The psychoses arising from organic disease of the brain are described under two divisions according as the lesions are diffuse or localized. slight changes in the cell and an increase Alzheimer sclerotic and a Binswanger psychosis 3 designate as arterio- insanity. 49. . 2 especially bodies. Diffuse Lesions Fuerstner has described a condition of superficial layers of the cortex gliosis of the with cyst formation and is atrophy of the nervous elements. LI.. f. children syphilis.. 1. vertigo. and a pro- memory. LUI. 809 . Zeitschr. called the it In there fibres. loss of Archiv. convulsive attacks. optic atrophy. characterized by gradual development with headache. with progressive mental deterioration. f Psych. Wochenschr. increase of the patellar reflexes and spasms. XXIV. which clinically gressive mental deterioration with weakness of rep- resented by infantile convulsions or imbecility. klin. tabetic speech disturbance. Homen 1 has called attention to a condition similar to the form of paresis in delayed hereditary endarteritis. Allgem.

and is characterized dilatation of sive by an atrophy the ventricles. and many remissions with transi- tory periods of brightness and normal behavior even in physically by disturbances of speech. of the corona radialis with is Clinically there progres- dementia with many persistent focal lesions. abscesses. sometimes also in circumscribed paretic areas. and scanning speech. and thrombi. . involves especially the posterior portions of the cerebrum. a certain insensibility. The mental condition accompanying multiple sclerosis depends upon the diffuseness of the process. Arteriosclerotic changes in the other organs are prominent. neurones. and degeneration and atrophy of the cortical isms. In large brain tumors the mental symptoms are more apt to depend upon the intracranial pressure. intention tremor. and frequent circumscribed paralyses. which appears in senility. Binswanger has also described encephalitis subcorticalis chronica progressiva. and dementia. hemorrhages. causing disintegration rather than displacement. both and aphasic. the most important are tumors. the mental If symptoms may be very slight until near the end. dilated lumina. Localized Lesions Of the localized brain lesions. thickened walls. and there is an increase of neuroglia. In the diffuse lesions there are general progressive mental deterioration and confusion or excitement. and apathy which increases to lethargy.250 FOKMS OF MENTAL DISEASE stupidity. as well as nystagmus. many miliary aneur- and capillary hemorrhages. memory. emboli. the tumor is of slow growth. The It appears from the fortieth to the fiftieth year. and as such consist of dulness. vessels present diffusely.

Besides showing a constant tendency to excitability. in which there may be some lessness. indifferent. petu- and quarrelsome. the cially memory is found to be defective. a great tendency to fluctuaare at one time the patients lachrymose. slow pulse. as. Cheyne-Stokes respiration. espewith reference to the time of occurrence of events former life. difficulty and slowness of In Occasionally ideas of persecution appear. there frequently failure of memory for certain definite groups of ideas. and epileptic attacks. and even stupid. In more rapid cases of traumatic character. When by motor resistance and loud the patients become oriented and of late quiet. These latter states are often associated with postapoplectic and epileptiform attacks. is emotional attitude there tion. Extensive lesions in the cortex produce general mental enfeeblement with dejective judgment and thought. they may also present transitory periods of motor excitement. Besides this. when stupor appears with or without convulsive attacks.ORGANIC DEMENTIA Cerebral abscess of gradual 251 development may be un- accompanied by any mental symptoms until far advanced. at others careless. Moral obtuse- . Patients of good mentality are. confused sometimes accompanied talking or outcries. or delirious behavior rest- with incoherent speech. lant. with great talkativeness and expansive ideas. because of aphasic or paraphasic disturbances. resistance. stupor is the most prominent symptom. for this reason. their Many are quite is unable to calcu- time. very difficult to estimate the mental capacity of patients. The mental disturbance accompanying rhage or embolism at the time of the insult consciousness with disorientation and cerebral hemoris one of clouded actions. sometimes considered imbecile. for proper It is often names and numbers. sometimes associated with aphasia.

and the . loaf. especially in differentiation from dementia paralytica. which from a few hours to several weeks. deviation of axes of the eyes and of the tongue. is no insight. A head considerable group of cases of is mental disturbance follow head injury. The patients may begin to drink. as well as the great selfishness and lack of interest in matters which formerly most concerned them. There is alteration consist may imusual fatigue almost always increased susceptibility to alcohol. injury. Difficulties in diagnosis arise in most of these different mental disturbances. there that the of may be no This symptom except man is changed. the clinical course of the psychosis. They are usually irritable.252 FORMS OF MENTAL DISEASE ness becomes evident in the lack of regard for the family and social customs. without memory for passing or previous events. The secondary effects appear as a permanent change in the personality. moderate depression. unwonted timidity. and defective hearing. In this state may the patients are completely disoriented. The etiological factors. a very vague last memory. is Insolation regarded as a form of The immediate result of severe cerebral con- cussion apt to be a condition of unconsciousness. and squander their property. the character of the onset. and a tendency to irritability which may extend even to an exhibition of passion. and often restless. striking Following the injury. or at most. sometimes talkative. odical exacerbations of the Peri- Among the the nervous symptoms is a striking feature. symptoms the most prominent are convulsions. and show a marked tendency to fabrication. upon slight exertion. irresponsive or unequal pupils. forgetfulness. inattention. Thought is slow and difficult. There emotional.

Symptoms indicative of a circum- scribed lesion do not point to paresis. and a few cases and also in cal- traumatic psychoses with depressed fracture of the varium. abscesses. . Success in traumatic cases depends in great part upon the If some time is allowed to elapse. improvement following operations is only transitory. or with the formation of haematoma of the dura. Brain tumor is occa- The treatment lesions.ORGANIC DEMENTIA 253 character of the nervous symptoms are the most important aids in the diagnosis. is of little avail except in syphilitic focal of tumor. sionally mistaken for hysteria. time of operation.

and the lat- somewhat age. to be distinguished or is a premonitory symptom of acute delirium. The mental in disturb- ances of the period of involution. panies hysterical insanity. it simply expresses an emotional applied here. and senile dementia. ship to lution. represents 254 Melancholia. whether it enters into the picture of dementia paralytica. used in a narrow sense. are always. In this broad sense state. is from the melancholia of some other writers. MELANCHOLIA Melancholia is restricted to certain conditions of mental It depression occurring during the period of involution. as involution psychoses. as two groups of cases. or accometc. described seem to stand in a causal relationthe general physical changes accompanying invo- The relationship is quite apparent in senility. in spite of many symptoms common. of a different stamp than those characteristic of old Those occurring in the former period are called melancholia and presenile delusional insanity. who apply the term to any condition of depression. melancholia. presenile delusional insanity. Naturally there is no distinct border line between the period of evolution and involution. but such changes may become evident in the characteristic mental disturbances occurring as early as the fifth decade. ter senile dementia. which are .INVOLUTION PSYCHOSES The three forms of mental disease.

and surgical operations. vertigo. with moderate clouding of consciousness and disturbance of the train of thought. seem to play a rather important part as exciting causes of the disease. indefinite pains. Defective heredity occurs in a over one-half of the patients. the loss of friends. loss of of — appetite. of which the most prominent are persistent headache. while in men little the onset is later. constipation. fears. from acute and chronic diseases. seldom earlier. In women the disease appears a seeming to bear a relation to the climacterium. and find no enjoyment in their work or home environment. and apprehensive. are little women. They are overpowered by doubts. The onset is gradual. months. External influences. Pathological Anatomy. They complain of being dumb. occurs under forty or over sixty. confused. and in- creasing difficulty with work. illness such as mental shock. and of a hypo- chondriacal nature. — Tbe anatomical changes which arterio- have thus far been noted are only those of sclerosis. Etiology. extending through months and sometimes even years. refusing to and self-accusations. very often exist for many Prodromal symptoms common. The First Group of cases is the more Symptomatology. The majority It of cases occur between the ages of forty and sixty. of persecution. The patients become sad. palpitation the heart. various delusions of self-accusation. be consoled by friends. general debility.MELANCHOLIA characterized 255 by uniform depression with fear. . feel ill. leading in the greater number of cases after a prolonged course to moderate mental deterioration. dejected. Sixty per cent. — The disease should be regarded as one of the evidences of beginning senility.

A religious strain is very prominent in many. reproach themselves for everything thing right. Many refer to former sexual indiscretions. or may be maintained with great firmness for a long time. Other delusions of fear are those of punishment for past misdeeds. the death warrant . . misdeeds are referred to in going over their past tions which are held basis for their depression. People are waiting outside to carry them off. The patients .256 FORMS OF MENTAL DISEASE forgetful. During this period there are occasional days when they are free Patients from apprehension and sorrow. others own mis- want for food if they eat. The patients believe themselves damned they will be turned out of their home. disobedience to parents friends. and and find it difficult to do anything. as an adequate These retrospective self-accusa- form a prominent symptom. They are perfectly wretched about it. Remote and often and neglect of in- significant facts are recalled. the lamentations of a their fellow patient are directly the result of deeds. or have sinned against the Holy Ghost. of special anxiety to themselves they cannot do anyEverything in the environment is a source . to court. They are wretched because they are not as fervent in prayer as formerly they no longer possess real religious feelings. Delusions of self-accusation become prominent. . A patient was miserable because she had requested her sick sister to remain out of the kitchen another because at the death of her mother she had allowed herself to think of and mention the division of property. or killed outright. such as the stealing of fruit in childhood. by God . many life. which now cause them the greatest anxiety. become retrospective. These references vary from day to day. brought thrown into prison. Their whole life has been made up of similar misdeeds.

MELANCHOLIA is 257 already signed. in order to secure severer punishment and obtain relief for their guilty consciences. eat sparingly or not at all. the lost. away as the result of former They fear that they are dying of consumption or cancer. they have only a short time to Hallucinations of hearing and sight accompany this condition. These depressive delusions so thoroughly influence their actions that they become seclusive. some great calamity will them. They also express considerable apprehension for themselves and families . and even ask to be put out of the way. Sometimes they even exaggerate their misdeeds and confess crimes which they have never committed. the children will robbed and killed. fail to mostly well recognize where they are. but they are usually indefinite and of short duration. They would rather starve and suffer for their misconduct. Patients insist that they are the most unfortu. claiming that they are in a prison. oriented. In other cases the delusions are hypochondriacal in nature. ness is The are conscious- usually clear. and clothe themselves and their children scantily. however. banishing all appetite. lungs are filled up. but in spite of this it may be readily seen that they comprehend well. and now they must starve. There is no need of taking food. They give up everything because live. they will visit be deprived of their home. will die. refuse to spend money. . They maintain that the body has been poisoned. shrunken. and they may mistake strangers for acquaintances. or they themselves will be be driven from the church and damned by God. The patients They may. nate individuals in the world the stomach is gone. and that they are going out of their minds and must end their days in an asylum. and all sensation The brains and nerves are rotting sexual abuse.

and some motor unrest. great clouding of consciousness. into their illness. recounting their mis- Thought deeds and the dreadful things to happen. attempting to remain at work and to busy themselves in order to drive away their loses bad nance is sad. sitting They may be hands. let me go home I want to see my children. indolent. and sometimes even nihilistic. There is usually some insight I want to see my children. and the listless. Very many are restless. the patients complaining that their is head not right. but are not uniformly retarded. The slight depression soon gives way to extreme dejection. and even days. The patients accuse themselves of horrible . but with a few they come as an impulse. which are apt to be extremely silly. and readily submitting to treatment. this rather Attempts at suicide are frequent in form. the figure may be low and feeble. individual movements are feelings. as " Let me go home. many hallucinations. but the content is usually centred about the depressive ideas. but at the same time failing to recognize disease as such. as in manic-depressive insanity.258 FORMS OF MENTAL DISEASE is coherent and relevant. with folded keeping to bed. especially in cases with prominent exciting causes. and very often are the result of deliberation." . The prodromal symptoms and the onset are usually similar to those of the first group. The onset may be more rapid. The counteThe voice its elasticity. or for hours. The Second Group of" cases is characterized by a greater predominance of delusions of fear. Very often they show a tendency to repeat certain phrases. many symptoms of the In conduct the patients show a certain constraint and lack of freedom in movements. to which they always recur with great frequency.

the eyes are rotting away. 259 which have led to their banishment or to threatened have murdered their husbands. there is cities. Occasionally sexual delusions a silly character are present. no one should speak to them. should be buried alive. the tolling of the church bell indicates that some one has died. Things about them seem unnatural and have a gloomy aspect. when the patients claim that nothing no more food. devoured their children. and the brain is solid rock. External associations enter into and play an important part in their misery. no wife. They are totally unworthy. They cannot eat. Everything is awfully changed to them. hanging is too good. no one is alive. They themselves have no name. no more trees. no sun or moon. A spoon lying on the table means that medi- cine has been taken. they have desecrated the communion bread. friends and relatives are different. All wickedness is due to them. no more houses. exists. maggots are crawling under the skin. The depressive delusions in some cases become nihilistic (delire de negation). The end of the world has come. have brought sin upon the whole world. or night. no day no They are alone in the universe as there is no world. or have spat upon the image of Christ. execution : passing carriages are regarded as a funeral procession. and the house is transformed into a dungeon. the patients . and they should be thrown into molten metal. cannot speak. cannot of die.MELANCHOLIA crimes. the sun and the moon do not shine the same. The patients claim that they have no breath. and some one nails is now at the point floor Hammer and found on the mean that a scaffold is being secretly built for their execution. the blood has stopped circulating. are apt to The hypochondriacal ideas be extremely absurd. they are now to be passed into a lion's den. of death. no children.

The is increased by association with those who are accustomed to arouse in them the deepest feelings. the devil speaks to them. women. and smell vapors at night. Voices are heard. Some patients claim that it is as if a heavy weight was upon the chest. Patients thoughts of others. in the expression of which the patients are apt to show considerable Sometimes did I do? single phrases are repeated for hours. showing disorientation for time. and to clearly describe their symp- toms. Occasionally they detect strange odors and tastes in food. There are a few cases. and hear the evil bells are heard. and inner anxiety. The basis for this emotional depression seems to be fear. is various delusions. Emotional outbreaks are may be present at times. and feel as though homesick. are now in a house of ill repute. They are timid. while strangers and new environment create little emotional fear reaction. especially those with progressive mental deterioration. they see strange forms beside them at night. in which a few expansive delusions appear. and repetition. as " did I do prising. cases is Consciousness in this group of usually much clouded. a feeling of oppression. or surrounded by men disguised as coherent. when the patients greatly agitated. and usually well retained. place. uneasy. to find that they are able to answer questions coherently. These depressive delusions are definite.260 FORMS OF MENTAL DISEASE maintaining that they have been outraged at night. ? What It is what sur- My God ! my God " ! sometimes however. moving bodies and spirits. and persons. Hallucinations of both hearing and sight are very prominent. and may even . strangers call them names and blaspheme. limited to The train of thought shows confusion. The emotional attitude is uniformly one of depression.

disturbed by dreams. MELANCHOLIA present a 261 dreamy disturbance of consciousness. The nutrition suffers and the weight sinks. stereotyped movements. In their anguish some beat themselves. Physical Symptoms. and are able to sit or lie quietly most of the time. Some of the patients are more composed. The sleep is scanty. In conduct the patients are restless and agitated. A few cases present symptoms similar form of dementia praecox. the tongue is and the breath foul. and echolalia while true negativism. These fre- quently follow visits of relatives or some unusual occurrence. neglected. wringing their hands in agony. pull out their hair and pick at their finger-nails. bewailing their misfortune. another devoured the ends of sulphur matches. There are apt to be numerous subjective sencoated. constrained positions. The mucous surfaces are anaemic. as " Tell The attire . or pacing the floor. they are not uni- formly retarded. Appetite is poor and digestion is de- — fective. in the accomplishment of fairly . While the individual movements are often slow. . only occasionally rising to gaze about them in fear or perplexity. fracturing her skull in several places.and general appearance are entirely The frequent attempts at suicide are here more result of impulse. and without any regard for pain. constantly repeating over and over single me what shall I do. as the patients are able to execute orders readily and quickly. mannerisms. Others groan and tremble. what shall I do ? " In this condition they have no time nor desire for eating. catalepsy. often the which some hack themselves to pieces one woman reduced her scalp to pulp with a hammer. to those in the catatonic and impulsive actions are rarely encountered. the bowels are very sluggish. such as stupidity. phrases. and unrefreshing..

In cases duration. physical symptoms. Circulatory disturbances are often present. a prolonged Course. — of recovery the to whole course lasts at least twelve months is two years. Short remissions.262 sations about FORMS OF MENTAL DISEASE the heart. as the result of annoyance. such as palpitation. while in the depression of the manic-depressive patient there is retardation and slowness of involuntary move- ments. and the apprehension gives way to irritability and fretfulness the patients then begin to . Diagnosis. cessation of the menses. The irritability of the melancholiac expresses an . uneasiness. limbs. such as A gradual improvement of the that induced by visits." during which they are troubled and apprehensive. not unusual for them — The greatest difficulty arises in distinguish- ing those cases of the depressive form of manic-depressive The insanity which appear for the first time in involution. and excitation. In melancholia the actions are all the natural expression of the anxious and irritable state of the emotional attitude. occur Exacerbations often arise longer and more marked. grayness of the hair. as cyanosis. display interest in work and reading. fatigue. may be regarded as a favorable sign. Other changes indicative of senility are sluggish reaction of pupils. it is to have " bad days. during which there disappearance of only a partial throughout the whole course. especially an increase in weight. essential difference is found in the psychomotor condition. and a still more gradual convalescence. arteries may dryness and harshness of the skin. and the give evidence of beginning sclerosis. and a feeling of pressure. The remissions become the symptoms. There is a gradual development. Even when con- valescence is well established. coldness and edema of the The pulse may be small and irregular or slow.

the emo- tional attitude does not always correspond with the ideas expressed. the remaining two-thirds undergoing mental deterioration. fail to who show deeper deterioration. but the patients to develop interest in the surroundings any kind Others. and indifferent. less onset following definite prodromal clouding of consciousness. symptoms greater or a more consistent emotional . and finally succumb to some infecThe prognosis is less favorable tious or chronic disease. taking little exercise and insufficient food. However. of work. In those who improve. being apathetic and anergic. and the consciousness fail becomes perfectly clear. not favorable. after the disappeargain insight ance of the marked delusional . become more and more emaciated.MELANCHOLIA inward anxiety. considering is that only one-third of the cases recover. defective silly time orientation. the depres- sion with the delusions disappear. state. is — The prognosis more deeply clouded. and to adapt themselves to They are dull. over fifty-five years of age. The patients. within two or three years. delusions. at least one-half the cases improve so as to be able to return home and live comfortably. attitude. sometimes aiding in Almost one-quarter die of intercurrent affections. mostly tuberculosis. but do not recover. and contradictory Furthermore. In melancholia one finds a subacute Considerable trouble maybe experienced in differentiating dementia paralytica. the maintenance of the family. but manic-depressive is 263 irritability the occasional of the accompained by some pressure of activity in conduct and speech. and consciousness Prognosis. stupid. poor judgment and memory. while in dementia paralytica there a gradual onset with early evidence of mental deterioration. and absence of evidences of mental deterioration is early in the disease.

regulation of the intestines usually improves the appetite. and can heal disease. Treatment. It is — necessary in most cases that the patients be confined in bed with short intermissions. unfavorable outcome appear to expansive delusions. with attendance. of the which recover tend to recur. and the appearance of silliness. given in small quantities and at quent intervals. while The patients believe that they have depressive ideas are maintained. cases Fifteen per cent." which should include the removal of the patient from irritating persons as well as objects. They are forget- apathetic. sight-seeing. Indications of an Residuals of former delusions as well as a few hallucinations and some expansive ideas remain. Monotony should always be Careful avoided by consulting the tastes of the patient. such as might be afforded by long journeys. Next to forced rest in bed comes nutrition. Other favorable changes are abatement of the excitement with retention of the delusions. The first essential is the establishment of " a rest cure. These ideas rarely influence the conduct to any extent. but in these the first attacks are very light. and entirely unable to apply themselves. have been called of God. Extreme anxiety and restlessness often necessitate artificial feeding by stomach or nasal tube in order to maintain nutri- . and ful.264 FORMS OF MENTAL DISEASE to recover coherence of thought. sufficient In very light cases a suitable found in removal to a different boarding-place or into the associations of a and constant change may be happy family. have been endowed with some special powers. when the depressive give way These are rather scanty and weak. become wealthy. The patients sometimes regard those about them as important personages. It is decidedly not advis- able to attempt distractions. in diet The food fre- should be nutritious. and constant company.

This care must be as strenuously observed until recovery is established. . 265 difficult Insomnia. should be given in rapidly increasing doses. the bromides. even reaching drops of the tincture of opium three times is daily. appears rapidly. often render is always inis advisable because of the prolonged course of the disease. be gentle. which is is troublesome and often to overcome. as the restlessness fails.MELANCHOLIA tion. best relieved to one-hundred degrees). This drug sometimes not only to occur. For this reason the manner should and assuring. hypnotics unnecessary. if it is Improvement from source. sulfonal and trional in ten to fifteen grain doses. The distressing condition of anxious restlessness may be It combated with opium or morphin fifty to sixty in increasing doses. Of the other hypnotics. friendly. . as difficult to thwart in their attempts at suicide. modifying the delusions. the use of which These measures. subsides. which later gradually reduced. The rest in bed dencies necessitate melancholiacs are the most should not be too prolonged daily change of scenery. later it is best that it be gradually replaced by short drives or walks. combined with The psychical influence which may be constantly exerted over the patients by those in attendance is of the greatest value in alleviating distress. Of the hypnotics alcohol the most valuable. or paraldehyde one-half to one fluid dram are the most useful. and relieving the anxiety. which by warm baths (ninety-eight may be prolonged for an hour. careful but serves this to aggravate the symptoms. well carried out. Hot malted milk before retiring may aid in inducing sleep. and attempts should always be made to lead the thoughts of the patient away Visits from relatives are from their depressive ideas. Suicidal ten- and constant watching.

Melancholia. it is deleterious in the height of the disease. S. u. Bd. und Behandlung der Melancolie in der Praxis. 1881.. Monatschr. of utmost importance that the patients be kept under observation and treatment until thoroughly recovered. Hoch. De la Melancolie. Etude sur la Melancolie. Die klinische Stellung der Melancolie. f. Ziehen. normal BIBLIOGRAPHY KraffcEbing. Neur.266 FORMS OF MENTAL DISEASE Finally. Psy. 325. Erkennen 1897. Roubinowitsch et Toulouse. Kraepelin. La Melancolie. Reference Handbook of Medicine. Voisin. 1897. Christian. . 1902. A safe index of this may be found in the insight into the disease their and the return of sleep and nutrition to state. 6. Die Melancolie. 1876.

and greatly praecox. accompanied by numerous unsystematized. The patients at first become quiet. and irriDelusions gradually appear which at first are quite table. Symptomatology. whom the disease appears between fifty-five . while in men it occurs about There seems to be marked hereditary As no other reasonable predisposition to the disease. — The onset of the disease is gradual. hypochondriacal. moody. Etiology. Among the first delusions to with a change of disposition. and persecutory delusions.PRESENILE DELUSIONAL INSANITY There lution is a small group of cases appearing during invoeither melancholia or senile de- which are unlike mentia. are The majority women. but later become more persistent and assume definite form. suspicious. 267 . it is assumed that we have to do with a disease of premature senility on the basis of a to sixty-five years of age the fiftieth year. occurring only twelve of the cases times in ten years' experience. The ever. seclusive. a if fact that the persecutory delusions of the genuine senile presents many similarities supports this view. partaking more of the characteristics of dementia It has been tentatively differentiated and characby the gradual development of marked impairment of judgment. cause can be assigned. discontented. is How- more extended experience is necessary to determine this a particular disease process. morbid predisposition. terized increased emotional irritability. — The psychosis in is rare. vague and transitory.

to blow up the house. troubled dreams. and seems surprised and alarmed upon his return home. or making them ill for the purpose of studying the case. ing one very etc. The patients claim that that articles their clothing has been exchanged or stolen of furniture have been removed and others of less value . leaves home. of flirting with every one he meets.268 FORMS OF MENTAL DISEASE The patient arise are those of a hypochondriacal nature. They suspect poison in the food rid of them. complains of the most varied and changeable nervous sensations and pains. It is characteristic of all these delusions that they are exceedingly unstable. . form. There are thieves about. These however. substituted. remindideas.. usually become more senseless. and has intercourse with every one The husband is suspicious of his wife because she leaves him at night. and all strength departed. malaise. is Delusions of infidelity are apt to be a very prominent The husband accused of eyeing women on the street. of accuse the physician of trying to get behaving in an obscene manner. which often are quite fantastic. debility. vertigo. there apart because One patient had her was some one concealed sofa taken in it who wanted feature. of caressing the arranges to servant. Other delusions apt to appear are those of persecution. roaring in the ear. They spring up at one moment. He from the schoolmates of his meet women whenever he possible. Many patients admit that they and again recur in another might have been . of removing the womb. much of hysterical complaints. and receiving letters daughter. the brain shrunken. The husband believes that the wife is dosing him secretly. are abandoned in the next. when the patients state that the spine is dried up. spasmodic twitchings.

The patients perhaps are threatened. fail to find they connubial infidelity was violated with such shamelessness they see may and slyness in their is own presence. is while the consciousness of the patient He cannot see the senselessness of the delusions while he allows himself to be persuaded. he cannot be convinced. At night dark forms stealing out of the room. However. dead. The patients then talk a good deal. . Perhaps a you will find them in the greatest distress because they have been poisoned. but judgment shows a marked weakperfectly clear. .PRESENILE DELUSIONAL INSANITY mistaken and that they are half-hour later sick. The memory for remote events is unimpaired. ness. make verbose complaints. attitude at first it is one of depression and Later occasionally leads to suicidal attempts. there usually appears some excitement and irritability. or It is a noteworthy feel some one lying beside their wives. They surely will die . 269 fail but in reality they to appreciate the senselessness of their ideas. in his narration of his delusions. Consciousness unclouded and orientation unimpaired. they simply express anger because any one. noted in the retention of the most fantastic delusions. a peculiar feeling about the heart indicates that their son A soothing word usually suffices to quiet must be them and dispel all apprehension. make further attempt to patients do not that the fact If a search is instituted and intercept the guilty parties. The emotional fear . or because some one has hidden under the bed. Thought is coherent. The cries of their ill-treated children reach them. Hallucinations accompany the delusions in only a few cases. he adds all sorts of em- bellishments and misrepresentations. or hear strangers boast of intercourse with their wives. stir up boisterous scenes. fly into violent passion.

become more senseless the patient claims that the wife and children are being tortured. and solicit much advice without attempting to follow any of it. or suspended on a fence. — With the advance . Female patients believe that their husbands have intercourse with their own children. One and the supposed seducers may be publicly patient went to the police to have a young of the disease the delusions unmarried lady placed under surveillance. their own bodies are disfigured and influenced. Course. sometimes refusing to speak and then suddenly becoming very for that reason friendly and communicative. quently. and every one talks about it. even temporarily falling These delusions change freinto the background. speaks to the patients. and become violent. but they are usually quieted without They sometimes laugh and cry without difficulty. withdraw from their associates. The precious Lord proclaims everything. the son nailed to the floor. destroy every- thing within reach. and even with other men. disguised as women. veil themselves. the search of them. to strict surveillance of the Jealousy leads letters in the is sent out in waste basket are placed together in order to obtain proof husband or wife. accused. The conduct actions. re- although some general signs of them are constantly . Persons and environment are changed.270 FORMS OF MENTAL DISEASE and are abusive. Nightly the wife wanders about from one place to another. torn The servant of guilt. They become aware of this by sensations in their own body whenever they are deceived. Some stop eating. Many patients remain in seclusion. cause. is characterized by all sorts of senseless In accord with their delusions many patients run about from one physician to another. lies near them in bed at night like a shadow.

the patients continue irripresent catatonic refusal of food. in fact even force themselves into their company. but are frequently considered as having been seduced. obtuseness . Diagnosis. By others this group of cases might be considered as belonging to dementia praicox. occasionally manifested. although not frequently. . mutism.PKESENILE DELUSIONAL INSANITY curring. The only consider- ation against this view is the fact that the patients do not symptoms. 271 But in spite of progressing mental deterioration. they do not treat the supposed persecutor sociate with their as especially hostile . The resistance. They often like to remain in the hospital in spite of complaining of all sorts of persecution. and excitement. in that the delusions are not systematized and there no attempt made to trace their origin to a definite source. they as- faithless wives. the delusions do not continue stable. but depend upon There is no emotional the delusions or the moods. and take pleasure in protection which is afforded them there. but change frequently and sometimes even in a short time. The persecutors remain indefinite or change frequently. on the contrary. and they quickly become agreeable and friendly toward those persons whom they have just previously suspected and accused. Moreover. the patients do not become incoherent. but they certainly differ from paranoia. the patients do not establish any broad basis for action from out of their delusions. are not simply compulsive or instinctive. and except for their occasional violent outbreaks. Finally. Their conditions of excitement seem to depend less upon deliberation than their emotional vacillations. which undoubtedly occurs at this age. — By some these cases might be regarded is as paranoia. and the suspected consorts are not regarded as enemies.

.272 FORMS OF MENTAL DISEASE judgment greatly predominate table while disturbances of over that of the emotions and actions. with isolated. and incoheare rent delusions. changeable. in which case neither the discipline nor the lack of freedom encountered there cause them annoyance. — profound dementia or confusion of speech. but by a moderate deterioration. Recoveries or marked improvement not likely to occur. — There is no special method of treatment patients Many who are a source of trouble outside need hospital treatment. Treatment. Some patients are able under favorable conditions to remain at home. The outcome is never characterized by Prognosis. applicable here.

dep>ending upon sclerosis of the brain. There may be compensatory thickening of the cranium. of cases. and senile delirium.SENILE DEMENTIA those forms of mental disease of involution. contains many corpora amyt 273 . its appearance after some acute Defective heredity occurs in about fifty per cent. simple senile deterioration. interna hsemorrhagica often present. atrophy of the nerve substance. are The Pacchionian Pachymeningitis granulations increased is in size. may present the picture of any one or these Etiology. the primary and fundamental symptom of which is progressive mental deterioration. The brain weight is from two hundred to five hundred grams below normal. but encountered most frequently between occasionally disease or mental sixty makes shock. both macroscopically and microscopically. dementia present. All advanced cases of senile Pathological Anatomy. The pia is somewhat thickened uniformly over the entire cortex. — usually adherent to the calvarium. A single case in its all of course forms. The cerebrospinal fluid is usually increased. Senile dementia includes the appearing in period It appears in three forms. The most important etiological factor is mental and physical overexertion with indulgence in excesses. senile confusion. producThe dura is ing what is called hydrocephalus ex-vacuo. — The is disease may appear at any time during It involution. and sometimes to an extreme degree. and seventy-five years of age.

The cord . exhibit arteriosclerosis These arterial changes may be either diffuse. Nissl granules staining deeply also takes . The neuroglia cells are much increased in The physiological increase of the yellow pigcell ment in the bodies. the volved. and the gaping fissures are filled Minute hemorrhages are often in with edematous pia. called etat crible. found in the cortex and frequently in the corona radialis and basal ganglia. sometimes triangular. there is fibres in the corona. cially in the lenticulate nucleus. the achromatic substance ill on the stain. accompanying advancing age.274 lacea. comprising pigmentary degeneration. basal ganglia. here goes on to a pathological condition in many spinal cases. number. with edema. FORMS OF MENTAL DISEASE and is almost always edematous. ventricles are much dilated and ependymal wall thickened. its contents being stained. sent various stages of arteries The choroid plexuses usually preThe cerebral cytic degeneration. becoming defined. The gives rise to a spongy appearance. or may involve any one of the smaller or larger arteries entering the cortex and the subcortical substance. but rarely granular. In the cell . there is a degeneration of the nervous tissue about the vessels. with miliary aneurisms. Plate 4) The cell body becomes shrunken. the nucleus is elongated. The neurones of all layers are in- body the pathological change most frequently encountered is the chronic change of Nissl (Figure 6. tortuous. and threadlike. of the nervous tissue is The sclerosis intimately associated with these arteriosclerotic changes. Foci of softening are often present In the corona. which. The processes of the cell become narrow. and espein the cortex. The convolutions are narrow and shrunken. an atrophy of the cortical neurones and a proportionate diminution in the volume of the Microscopically.

to follow the trend of anything read or spoken to them. fabrications. and overlook Almost nothing new is acquired. busi- ness and the affairs of society are not clearly and readily . forget and cannot recall the names of recent acquaintThe present seems to pass without leaving a trace. for every one. Senility brings with it. There is patients fail The a progressive defect of apprehension. The Defective attention is in part accountable for this. The patients forget where they have placed things.SENILE DEMENTIA presents a similar atrophy in tracts. failure of memory of recent events is the most prominent. The other organs of the body present senile atrophy and arteriosclerotic changes. which leads to a dearth and similarity in the content of thought. fail to realize that they are repeating the same remarks that they made yesterday or a few hours ago. patients are also unable. a certain degree of mental and physical deterioration. its 275 ganglia cells and fibre Calcareous placques are sometimes found in the pia. on this account. The condition of the heart with chronic endocarditis and fibroid changes in the myocardium is of importance. when all kinds of fictitious events are mentioned. so that the border line — — between physiological senility and the state of mental alienation cannot always be a sharp one. ances. vanishes. to understand the connection of things . The memory for events of early life is well retained. as it interferes with cerebral circulation. Symptomatology. Simple Senile Deterioration. Of the individual symptoms. which in advanced cases forms the entire content of voluntary Gaps of memory are very often made good by speech. the existence of which for the patients immediately details.

276 FORMS OF MENTAL DISEASE comprehended. appointment of a conservator. in a great part upon the con- but indifference and lack of sym- pathy are prominent characteristics. little things are done to annoy them. The patients fail to enter into the sorrows and joys of those about them. necessitating the leads to other ideas of persecution. and finally they are de- prived of property. Expansive delusions self-inter- may also est appear. Some the patients display a certain stupidity. the feeling of greed overwhelming even filial is affection. In emotional attitude there a variation between elation and depression. extreme and tearful sympathy or happiness may be aroused on the slightest pretext. Here we find the basis for many of the delusions. Egotism becomes marked and with the gratification of personal whims precede everything. This may advance to genuine avarice. silly The and of the emotional attitude are both superficial tory . Assoof energy ciated with this activity there is often present increased sexual feelings. that which we call impair- ment of judgment. These are mostly of a persecutory char- acter the patients believe they are being neglected. peevish. and feel no grief at the loss of dearest friends. . childish behavior. depending tent of the delusions . Lack of insight into their increasing infirmity. and a feeling of confidence which leads them into foolish business schemes and outlandish adventures. They states transi- are also irritable. leading to errors in formation of opinions and in the motives for action. and discontented. In actions the most noticeable features are delirious restlessness at night of and silly. Others exhibit restlessness with some exaltation. with a loss and a tendency to sleep the greater part of the day. causing the patients to enter into improper sexual relations and in extreme conditions to expose them- .

busy them- selves with trifles. and call the physician by their They say they are twenty-five years of have had twenty-five children. They may grumble. with a constant reversion Many changing delusions are to the same senseless talk. thinking husbands' names. and sometimes Hypochondriacal ideas are promiof a nihilistic nature. they imagine that they possess much property. how- ever. age. and as such often appears as the final stage in simple deterioration. Senile Confusion. a marked limitation of thought. and rummaging chests and closets without purpose. The restlessness at night and indulge in and abuse in the consists of getting out of and dishevelling the bed. that they still have their menses. by leaning against a radiator a hole has been burned through the flesh into the lungs. and They are easily distracted and show are now pregnant. . and the liver has rotted bowels their passed has nent . its full grade of deterioration. or the date. the season of the year. eat. excesses. away. 277 Other patients wander about aimlessly. This form characterized by great disturbance of apprehension. make foolish plans. They are to be poisoned or murdered. Patients are unable to care for themselves properly. wandering about the house. The patients mistake those about them for old acquaintances. and are dirty about their clothing. . may appear at first is and run course as senile confusion. On the other hand. it night. expressed.SENILE DEMENTIA selves. — The second form represents a deeper Senile dementia. have not the least conception of where they are. hold an important position. the oldest of which is twenty-five years. with clouding of consciousness and disori- entation. or are in communication . both of depression and elation. curse. causing the heart they cannot speak. or sleep nothing to cease beating in weeks. vilest terms. They undress at midday.

the floor. tered here. 278 FORMS OF MENTAL DISEASE with God. elated — senile deterioration. picking into the corners. There is great activity doors and windows in fear. threats. In actions they display more or less restless activity. it frequently follows an acute illness or Patients suffer ing. and at others and happy. and delirious acIt often appears as an episode in the course of tions. destroying and smearing their clothing. Many of these ideas are embellished with numerous fabrications. and unintelligible words. They are completely disoriented. nourishment is taken. or laugh. see the devil. incoherence of thought. They regularly tear and throw about their bedding. and incapable of There is great insomnia. singing. which is especially marked at night. shout for help. little This form is characterized by a more Senile Delirium. acute onset and a short course with great disturbance of comprehension. are bewitched and poisoned. often Echolalia they rattle refuse food. and huge boulders rolled about the room. creep about the room. In emotional attitude the patients are sometimes apprehensive and dejected. and run about in a silly manner. The patients are very untidy. and very caring for themselves. and crawl about incomplete rarely observed. incoherent. or They hear crowds of men pressing upon them with knives. When occurring independently. addressing . resist. some mental shock. tear up the bedding. and flighty. Hallucinations of sight and hear- ing are frequently present. the house is being flooded. surrounded by mighty powers. The speech containing is is irrelevant. sometimes irritable.. The occupation delirium is frequently encounwhen the patients act in pantomime. They are anxious and restless. from many hallucinations of sight and hearvoices. sing. claiming that they are in the world below.

which — is inis to <2fJLs)u>4 <^&yCi^s(y^7to~ — Senile Handwriting Fig. On the other hand. with more or less complete return to clear consciousness. both aphasic and paraphasic. cattle. leading to collapse from loss of physical strength. and when compared with the handwriting of the paretic readily shows There is also general the difference between the two. in contrast to that of paresis. be distinguished from the tremor of the paretic by the numerous difference irregularities in the individual is movements. The course of the delirium is short. Speech disturbances are frequent. illustration of the The accompanying handwriting of the senile demonstrates this characteristic. and muscae volitantes are frequently present. 279 or driving horses. or it may pass over into a state of anxious unrest. ringing of the ears. and run a fatal course. and general fine tremor. Physical Symptoms. parsesthesia. anorexia.SENILE DEMENTIA imaginary audiences. The speech is. noticeable in the increasing muscular weakness and the wrinkled and faded countenance. muscular deterioration. which immediately discernible in the handwriting. This state of unrest appear. In senile dementia there somnia. and death by some intercurrent disease. Hyperalgesia. the delirium may reappear after short or long intervals. rarely hesitating. or in time entirely dis- In unfavorable cases the delirium becomes ex- treme. tending Insomnia is extreme. and presents many remissions. . 5. may persist.

The senile delir- disproportion between the emotional disturbance. The tendon reflexes are in- The skin and sometimes only on one side. the paresis in the limbs is associated with weakness of the sphincters. rarely absent. similar to dementia paraThe duration is from three to five years. nihilistic. while the epileptic attacks are ar- encountered in rare cases. — The course — of the disease is a progressive one to absolute dementia and death. It is a characteristic feature of these attacks that. there occur in very many cases apoplectiform These may be simply attacks of vertigo. also Genuine apoplectiform attacks with hemiplegia are of frequent occurrence. sluggish. importance from a legal standpoint. toms of pure senility to simple senile deterioration This is of extreme offers some difficulty in the diagnosis. The presence of delusions and of excitement should leave no doubt as to the presence of a psychosis. reflexes reflexes are abolished and the pupillary Associated with the changes due to diffuse lesions of the brain. as these cases cause more litigation than any other. The gradual transition from the sympDiagnosis. more often are conditions of prolonged somnolence or coma. .280 FORMS OF MENTAL DISEASE is Vertigo creased. but attacks. pulse The radial teries usually give evidence of sclerotic changes. entiated Senile dementia may be differ- from melancholia by the appearance of hypo- chondriacal. and the defect of apprehension and Dementia paralytica has already been differentiated under that disease. An lytica. and other silly delusions. accompanied by general paresis of the muscles. is and temporal and the slow and irregular. acute course may last but a few months. Course. during convalescence. These attacks are to be distinguished from apoplexy by the absence of hemiplegia.

. 101 . does not differ from the delirium encountered in other psychoses. 1899. Journal of Mental Science. except for the underlying basis of deterioration. Neur. An. Colella. XVI. can be relieved by use of morphin or In conditions of delirium. BIBLIOGRAPHY Fuerstner. 2. 1899. Diss. Senilis. are indicated. . attention to — Naturally the of sleep it the treatment proper is limited to physical needs. and improvement is by hypnotics. Monatschr. fail. In cases where there great anxiety. S. 519. Ueber Dementia f. Treatment. f Nervenheitke. 430-456. 265. and in case these measpadded beds or rooms. f. Campbell. Fltude sur la Folie Senile. Psy. with the addition of alcohol. 1898. SENILE DEMENTIA 281 ium. hygiene. u. XX. pro- opium.) warm baths. artificial feeding by stomach or nasal tube. 1895. 1894. Alzheimer. Zuerich. longed ures (See p. 6. The mild cases are best cared for at home. Psy. S. Archiv Noetzli. fasc. Annali de Neurologia. Centralbl.

viewed according to the old conception. mania. there appeared evidently maniacal symptoms. where one form passes over either gradually or rapidly into another. always presented difficulties because of the frequent occurrence of conflicting symptoms. flight of ideas with sound associations. the uniformity of their cess. and the picture of circular insanity was frequently marred by the appearance of two successive maniacal or melancholic attacks. In periodical melancholia. simple melancholia. simple mania. has led to the conclusion that the individual attacks appear in one of three forms. the depressive. periodical belong to this group. periodical melancholia. closes such varying features that one is forced to conclude that these manifestations. The maniacal forms are characterized by psychomotor excitement. and the occasional intimate relation of different forms of the disease.MANIC-DEPRESSIVE INSANITY This term is applied to that mental disorder which life recurs in definite forms at intervals throughout the of the individual and in which a defective hereditary endow- ment seems to be the most prominent etiological factor. or the mixed. periodical Any series of ten cases of mania or periodical melancholia. and circular insanity These diseases. in each of which dis- there has been at least three attacks closely observed. are not accidental. but phases of one disease pro- The constant recurrence of certain fundamental symptoms in all the attacks. The greater number of cases usually called recoverable mania. course and outcome. great 282 . inharmonious with the old conceptions. the maniacal.

In the excesses perhaps the greater number of cases. the first attack appears before twenty-five years of age. and usually clouding of con- sciousness. Such a conception of the disease. and acute diseases. alcoholic causes. some having been abnormally bright. mata may the first. of admissions to insane hospitals. is Of the etiological factors. little hallucinations. occurring in cases. deprivation. dearth tor retardation. 283 pressure of activity. and in less than ten per cent. nappy though. unsome unstable delusions. The mixed forms present a combination of the symptoms characteristic of each of these conditions. The disease more common in women than in men. with characteristic fundamental symptoms. without having to wait for the occurrence of more than one attack. defective heredity inent. prominent delu- sions and hallucinations. after the fortieth year. almost always appear independently of external causes. in both of which periods women . dejected emotional attitude. stable emotional attitude. Individual attacks. makes its recognition possible immediately at the onset. while Physical stigothers have been eccentric or overpious. excepting in imbecility and idiocy. many patients have displayed peculiarities. absence of ideas. The of depressive forms are characterized by psychomospontaneous activity. of than in other mental diseases. and comparatively clouding of consciousness. a larger percentage the most prom- from seventy to eighty per cent. Of external are most prominent. others are mental shock. Previous to the onset of the psychosis. except also be present. — Manic-depressive is insanity comprises from ten to fifteen per cent. Etiology.MANIC-DEPRESSIVE INSANITY distractibility. besides gestation.

which in the vast majority of cases is hereditary. childbearing. is still more improbable. flushing of the face and extremities. The apprehension and comprehension — of external impressions show more or less disturbance in the maniacal forms. and probably anemia of the brain. true. Meynert has offered a theory of the pathological basis of the disease in explanation of those cases which alternate from a maniacal to a depressive attack. — Thus far observation has failed to reveal any characteristic anatomical pathological changes.28-4 FORMS OF MENTAL DISEASE The first and subsequent attacks often and puerperium. which explains the disease by a trophic vascular disturbance. The prolonged vascular spasm in the depressive states would naturally be followed. except in the lightest — hypomania. distractihility This disturbance of the attention. This fact. He full observed that in the maniacal states there was a hard pulse. with a clinical picture of mania. these grounds Meynert advanced the theory that the disease was due to a vascular disturbance. Symptomatology. This theory is inadequate. or vice versa. In the depressive states the opposite was an unsteady weak pulse and vascular spasm of the Upon extremities. as the result of fatigue. is due largely to the great The patients lose the ability to select . A theory presented by Meyer. by vascular relaxation and cerebral hyperemia. but it is a pregnancy occur during noticeable fact that these do not cease with the period of predominate. because it does not establish a basis for the mixed states. Pathology. mostly independent of external causes. from which it was inferred that there was also a hyperemia of the brain. has led to the conclusion that the disease depends upon a neuropathic basis. together with the recurrence of individual attacks.

attendants. dimin- ished. as is seen in the remarkable insensibility to heat and cold. objects. from other sources perfectly clear that they do not comprehend their environ- In the depressive phases the disturbance of conis more pronounced. and even apathetic patients . although there is no serious disorder of the perceptive process. because itself each striking upon them so strongly that absorbs their entire attention for a moment. Their sensory stimulus forces attention may be held for a it moment by holding objects before them. however. and in the more marked stuporous condi- . unless and it is even surrounding ment. is quickly distracted by something Under these circumstances. and to pain. but else. sciousness Hallucinations are very rarely present except in the delirious form. and the picture remains disconnected and incomplete. while the next instant another stimulus takes its place. when the patients for months may fancy they experience the most extraordinary and dreamlike adventures. consciousness in the maniacal forms is The not clouded except in the more severe maniacal conditions and in the delirious form. to hunger. Even in the lighter forms the patients are unable to elaborate and comprehend well their impressions.MANIC-DEPRESSIVE INSANITY and elaborate it 285 their impressions. The central susceptibility to external impressions is. may be compelled to follow striking impressions. In the depressive forms apprehension is more manifestly and extensively disturbed especially is this true in stupor. particularly in stupor. when the hazy impressions and confused ideas lead to disorientation. the en- vironment is never fully apprehended. fellow-patients. Distractibility of the attention may be noticed. One should not interpret as disorientation the capricious and playful use of false names for the physicians. consequently.

which are held for some time. but they are not well conIdeas seem to crowd each other. There is usually some insight into the disease . objects that there is a multitude of ideas. The . In the deof perse- especially directed against the family. is The disturbance of thought followed out . and appear in the form of playful boasts and exaggerations. There is a lack of voluntary guidance of the train of thought. hence there are quick leaps in the succession of ideas influenced by happen to come into the field of vision. in the maniacal forms. and the line of discourse is lost in a mass of detail. they do not. variable expansive ideas may pressive phases. In the maniacal forms a definite line of thought cannot be from one subject to another.286 tions. on the other hand. but with the addition of a host of details and side remarks that have ideas pass abruptly only a distant relation to the subject. the delusions cution and of self-accusation. It is impossible for the patients to relate any event coherently without fre- quent inquiries and suggestions on the part of the listener to draw him back from his digressions. but in reality nected. A few patients elaborate delusions of persecution. In great excitement many be expressed. but while to misfortune the patients appreciate that they have undergone a change. as well as hypochondriacal ideas. are usually present. or by sounds caught up from the surroundings. "When present they are unstable. On the whole. they attribute it and abuse rather than a prominent symptom. or of poisoning. A short question may be answered correctly. These delusions rarely become fantastic. to mental illness. but FORMS OF MENTAL DISEASE even here they are neither a prominent nor perDelusions also play an unimportant part sistent feature. There is no controlling goal idea.

and another appearances. not of thought. especially those that play an important part in daily expressions. . complaining of abuse and or less elated and happy. causing the patient to appear stupid. crowd one another. objects Observation of external may seem it is to be very accurate and complete. until closer observation has demonstrated that is no real deterioration. In spite of retarded. but they do not There is an abundance of words. is and there really a dearth of ideas. Irritability is prominent. The reaction to questions is apt to be monosyllabic. A striking object attracts the attention.. but in reality superficial. there Such patients have been regarded as demented. but even more characteristic are the rapid changes in the emotional attitude in the midst of joy patients become tearful. Depression of . In the depressive and mixed forms there is retardation The process of thought is greatly impeded. misfortune . MANIC-DEPRESSIVE INSANITY association of ideas follows along the tracks 287 most fre- quently used. such as bits of slang and common phrases. in spite of profound misery they may burst out into boisterous laughter. there only flightiness and an instability. is Instead of an acceleration of the train of ideas. genuine thought is started. attitude in the maniacal The emotional forms is more There is a feeling of well-being with a tendency to joke and to make facetious remarks. These varying states appear and disappear with the greatest rapidity. Expressions of the emotion are unrestrained. of ideas. and starts a train of thought has proceeded far something else obtrudes is but before this- upon the sensorium. Ideas are rapid. is apprehended. The resulting incoherence of thought gives rise to the so-called flight of ideas. giving rise at times to outbursts of anger from trivial causes.

which are executed with unusual energy. The ready release motor impulses perhaps accounts for the unusual absence of fatigue in these conditions. Unrestrained activ- more impulses intrude before ity tends to increase the excitement. indicating a close relationship between the maniacal and depressed In this form depression is the predominating feaphases. the actions restless and an excessive is energy over trifles. or even is a volitional action accomplished. gloom. the removal of which offers a substantial relief. The intensity of the motor excitement depends largely upon external stimuli. or rest- mischievousness with anxiety. This is important in the produc- . almost imperceptible In the lightest forms activity impulses excite the greatest variety of movements. depend upon and bear a definite relation to the ideas and emotions. New any one object can be accomplished. Every sort of impulse leads to pletely inhibiting all if an action. The increased facility for the conveyance of stimuli into action gives rise to pressure of activity. The actions. begun. In the severest excitement the actions change as rapidly as the ideas. however. The mixed forms present stupor with less silent mirth. may and there is despair. ture. The most prominent symptoms are found in the psychomotor sphere. and often anxiety but even in their dejection one sometimes encounters moments when there are feeble attempts at laughter and even gayety. this appears a characteristic display of severe. This psychomotor pressure of activity is prominent also of the in the field of speech.288 spirits FORMS OF MENTAL DISEASE appear even for a few hours. it is overwhelmed before half Furthermore. . which may persist for weeks or even months without any signs of exhaustion. and are quite aimless. comnormal volitional impulses. If the disease become disconnected.

Run don't run west. devils at night. business. I am no street walker. hell. shell. The patients prattle away and shout at the top of their voice. east. but feet win the neatness of men. MANIC-DEPRESSIVE INSANITY tion of the flight of ideas. flag. store. perhaps ending in unrestrained laughter. set phrases. Instead of a logical sequence of ideas. For three years I got over seven dollars a month and some old rags. the sweet voice. but west runs Rebels don't shoot I like west strawberries best. and own fiddler. my me to love. slang. " I The following : production — is a sample of the maniacal was looking want sweet soap. the hand that off yesterday. Women should mind their own Fish-hooks are between the American blue. declaim with many gestures and in a pompous manner. Women pressed yeast.. God's laws are all right. and finally predominance of pure sound associations. dispositions 289 The easily aroused motor speech of thought than the ideas arising have a stronger influence in directing the train from purely intellective processes. and rhymes. at you. bang. but McKinley does not . bells. scream. hardware they shot hairs. slam. that does not You always work Harvard. when we hear such productions as " Sam. those associations we find that the motor coordinations determine their succession thus we encounter common in the every- day life. I am vaccinated. should never smoke. The I love of God don't win gray father taught I don't care am nineteen. Here if for the is the right hand. but Royal Baking Powder is comWomen should never chew gum. or they sing now softly. Neatness of feet don't win feet." etc. white. Take your time and be not disobedient. Fourth of July. I am no tobacco chewer. Silence is impossible. be grateful and when judgment day comes. red. now slowly. You must pay for your Prudence. jam.

My father is a Democrat. script is coarse The a retardation of activity. but even after being started may fail of completion. The above description of the symptomatology serves as a picture of the disease process as a whole. presents and rhyme. performed very slowly and without Unless extreme. The disease . overwriting. a senseless enumeration of and bold. but results direction to the train of ideas. but are soon resolved into catch phrases. In the mildest degree this retardation appears as a deficiency in the power of resolution. such are as walking and talking. The letter-writing of maniacal patients equal clearness the same disturbance. The psychomotor field. leaving the patient in a condition of stupor. from an inability to give A normal individual at if times might give expression to a similar production he could utter the sequence of ideas as they came into his mind. bits of slang. and punctuation marks predominate. and even the move- ments of expression are dominated by this same condition. He had no work for three years. while underlining. due to the slowness of conveyance of sensory and ideational stimuli into impulses. in the depressive forms.290 FORMS OF MENTAL DISEASE win. The simplest movements. energy. sentences shows with Single phrases and may be well started. sents In the disease picture this ideomotor excitability regularly leads to the expression of every idea that preitself. such as impending danger. when there may be display of considerable energy. Actions may not only be performed slowly." Such incoherence is not the outcome of an excessive repletion of ideas. In the severest forms the retardation leads to a all complete abolition of voluntary movements. the retardation may be over- come under extraordinary circumstances.

maniacal find It is a question whether this subdi- cases in which the and a patient in one attack may pass through the whole cycle of changes in since we many intensity of the symptoms varies. and apply themselves only to that which They show a morbid tendency to attract is agreeable. and The actual capacity for work. vision is justified. attempt journalism. depressive. we must regard them Each : as phases of one disease still groups has further been divided into smaller groups. . Further may groups. or mitissima. comprising hypomania. . and delirious mania depressive forms. renew old friendships. stupor. purchase property. They develop freaks of conduct devote much time to family genealogy. Maniacal States Hypomania This. begin to build. become negligent. After a short period of activity. according to the intensity of the symptoms maniacal forms. They lack perseverance. mania. there appears an unusual The patients are up at early morning. and stuporous conditions stuporous mania. however. The onset indisposition is often gradual. of these — but at present process. . and give : much time to pleasure. and mixed. simple re- tardation. mixed forms. has also been desig- nated mania mitis. the mildest maniacal form. all three groups. is much diminished. bustling about with unnecessary business.MANIC-DEPRESSIVE INSANITY picture as it 291 appears in the different phases needs a its more study detailed description for recognition. take long walks. and folie raisonnante. write many letters. — the lead to a different conception of the three large maniacal. retardation with hallucinations and delusions.

tion being centred about commonplace affairs. but in reality they cannot make use of any valid comparisons. as well as over their excessive activity. or those who have been instruof mental in their confinement. The patients are unable to arrange logically a series of ideas without abrupt transitions from one subject to another. . wear flow- and use perfume. The patients justify their actions against criticism fail for plausible ex- in a most persistent way. and never and this is cuses. and riences and difficulties. Usually. The memory events. There is complete absence of insight into their condition. FORMS OF MENTAL DISEASE they dress in a conspicuous manner. letters. In the realm of ideation they show a moderate flight of ideas. They believe themselves misjudged or falsely confined. They may appear brighter and clearer minded than usual because of their ability to grasp remote resemblances. In the highest grades there in is a strik- ing lack of coherence the train of thought. in their estimation. the relatives and friends. as they never were more healthy or capable of work. more especially noticed in from one subject to another. and tan boots. their is slightly is inaccurate only for . Upon effort they may be able for short periods to gain the mastery over their incoherent thoughts. and are quite unable to bring a thought to a logical conThey are very talkative. often distort the facts with exaggerations and frequent They shift abruptly misrepresentations. silk hat. their expeThey revel in minute details. A sedate old merchant persisted in wearing a red tie.292 attention ers. are the ones in need hospital treatment. recent Self-esteem very prominent they boast of own deeds and show a proportionate lack of ap- preciation for those of others. . the content of conversaclusion. colored hose.

clouding of consciousness and disorientation. they run back tory expansive delusions. They are jovial and friendly. The patients rapidly develop great psychomotor restlessness. following a short period of headache or A few days of simple depression may precede malaise. The duration is seldom less than several months. and sometimes over a year. and the weight may increase. they may show great irritability. and often accompanied by remissions. and the movements are strong and elastic. The improvement is very gradual. which quickly acquire an irresistible power over them. contented and grumble. The skin appears healthy. They take great delight in making facetious remarks and in taunting helpless patients. The regularly improved. with a pronounced flight of ideas. transi- and occasional hallucinations. Mania The onset of the purely maniacal condition is almost always sudden. Physical Symptoms. great impulsiveness. This condition often follows pure mania. and often exuberant. The course of this form is usually uniform except where hypomania appears only as an episode in the other forms.MANIC-DEPRESSIVE INSANITY 293 Patients are The emotional attitude is usually elated. The activity of mania is much greater than that of hypomania. When violent thinking of their restraint they of abusive anger. cheerful. happy. On the other hand. Patients cannot sit or lie still . They derive great pleasure from their associations and undertakings. . the onset. but their actual is profound. sleep — The number appetite is of hours of sleep is cut short by late retiring and early rising. fits may become disand when opposed may show They are completely under the control of sudden impressions and emotions.

. They are especially apt to cram the nostrils and ears with foreign material. and and prattle incessantly. smear the person and room with grotesque designs. and even dried feces. and to carry bits of glass. tear off cloth- down the hair. glass. sounds from the surroundings are caught up and woven into their speech an object held by the physician. Sexual excitement is manifest in shameless masturbations. from watch to shoes. exposure. Consciousness is more or less clouded. They are quarrelsome and domineering. sing. Apprehension and comprehension are greatly interfered with by the extraordinary distractibility . public officials. the most fantastic — In the absence of tobacco leaves. nails. . Bits of straw and pieces of stone. and bits of thread. or parts of his clothing. Those about them are apt to be mistaken for old acquaintances. 294 FORMS OF MENTAL DISEASE forth. ornament themselves in manner with clothing which has been Everything that they can lay their torn into strips. turn handsprings. all sorts of material are used. Patients know time and where they are. or mischievous and playful. the most trivial affairs may lead to extreme violence and abuse. dance about. or well-known millionaires. and demands for intercourse by indecent This is atti- tudes and insinuating remarks. pull make all sorts of gestures. Because of great irritability. ing. clap the hands. and nutshells in the mouth. as congressmen. shout. hands upon. is taken to pieces. seen in the partial or complete disorientation. but they perceive only in a superficial way the events of the environment. . A patient secreted a fourinch nail and an extracted tooth in his mouth for months. Sometimes they designate them as historical personages. Female patients are more apt to show this tendency than male. stones. and food are hoarded to plaster up a crevice in the wall or to pack a keyhole.

are and embellished by numerous fabrications. on the wall. shining objects appear Sometimes faces are seen on the ceiling. is and quickly lead the thought in which is just as abruptly left before half expressed. Sometimes they Delusions. can produce planets. often a patient shows some insight into his disordered condition. They present manifold changes. that they have supernatural strength. locomotives and poisonous vapors are set free in their rooms at night. assaults. elated. transi- The patients claim that they are royal personages or generals. is very marked. are transitory and changeable. and forgotten the next moment. seldom depressive. floors creak.MANIC-DEPRESSIVE INSANITY attract the attention 295 another direction. the thought to them. They understand what is said and are able to give short answers to questions which are correct and pertinent. flash-lights are seen as signals in the sky. The rapid In changes of the emotions are still more characteristic. mostly expansive. Trifling affairs. or destruction of the clothing or other objects. Many of these ideas are recognized by the patients as pure fabrications. A few Very single delusions may be adhered to for a long time. are prominent. aiding in the production of a genuine flight of ideas. feel electric shocks. bells heard. In this way facts concerning their past lives and occupation can be obtained by Hallucinations are apt to play an unimportant part and piecemeal. and Noises are ring. may lead to outbursts of passion with profane abuse. tory. such as interference or contradictions. and are related to God. wbistle. In emotional attitude the patients are mostly happy and Irritability. admitting that he is crazy and cannot control himself. are expressed with a laugh. on the other hand. .

— — with only slight fluctuations. Occasionally there may appear a sorrowful and depressed emotional condition. The patients immediately develop the greatest restlessness. The improvement there is is very gradual . and in some cases within a few days. and dreamlike delusions. and sometimes two or three years in reverses cause a recurrence of the symptoms. . following a few days of indisposi- and insomnia. to show a flight of ideas. The sleep is more or less disPhysical Symptoms. acterized char- by considerable clouding of consciousness. Delirious Mania is This. indicating a transitory depressive phase. The intensity of the disease is fairly uniform. and misfortunes. the most extreme of the maniacal states. tion. with disappearance of the motor activity. The onset is sudden. a high grade flight of ideas. and some increased activity. or even a transitory stupor. turbed and nutrition suffers in spite of increased appetite. . intense psychomotor activity. numerous hallucinations.296 FORMS OF MENTAL DISEASE the midst of joy they begin to lament and shed tears at the thought of home. trying conditions. The weight always falls. or because of the abuse which they claim to have received at the hands of their nurses. under strain. Course. The height of the disease is usually reached in the course of a week or two. Even after apparent complete recovery. uneasiness. although for some time after comparative clearness. great incoherence of speech. the patients are apt. Frequently they show a very sudden change to a condition of passion and rage. incessantly running about. and more often intoxication can The duration extends over many months. rare instances as long as five to seven years.

are numerous and are present in all of the sensory fields they see beautiful sights. stream and stamp their feet. pound the window or door. They see and hear the crackling timbers. mount the table and declaim in a loud voice with profuse and exaggerated action. is incoherent. which one can always detect many fragmentary references to objects in their environment. the roar of wild animals. The manifold changing delusions are both expansive and depressive they are the " chosen ones " have been .. Their food has a peculiar odor and fire taste. confused as to oughly take their environment. gestures. when a fragment of the desired response can be Striking objects. as a penny dropped on the floor. and a minute distastefully affectionate. 297 destroying everything recklessly violent. . MANIC-DEPRESSIVE INSANITY and singing. and The patients are thordisorientation is almost complete. will divert the attention and the train of thought for a moment. The attention usually cannot be attracted except momen- tarily. cannonading. becoming shouting themselves. and persons they mistime. and numerous repetitions of single syllables in and phrases. and even their friends. disrobing. abounding in sound associa- rhymes. . and scenes of torture hear distant music. within reach. race at the greatest speed along the corridor. such detected in the incoherent speech. and . at the singing next cursing with the obscene song language an at one time they are insulting in speech later are profuse in apologies and and They chatter away. Their speech tions. Dreamlike The hallucinations hallucinations and delusions appear. place. . and small objects crawl on the skin. and smearing or At one moment they vilest . ringing bells. are praying. From the first the consciousness is greatly clouded. strange faces.

usually within a few days or weeks. eral muscular tremor. and are inclined to be irritable and distrustful.298 FORMS OF MENTAL DISEASE . Finally in the course of a few weeks these signs entirely disappear. they have lost all are to be taken to the sea. Course. exuberance and apathy. or through some intercurrent disease. . must enter hell have been an immense height and are now to be cast into Some are on trial for murder. There is rarely for the events of the acute stage of the psychosis. or have been transmurdered . have wonderful power. hours. delusions The improvement some time of rapid. ecstatic joy and timidity. Irritability is very marked. during which the consciousness Short inter- vals of composure. friends . the height of the disease accelerated entirely lacking the pulse is and the reflexes are exaggerated. Physical Symptoms. and at . any memory A fatal termination is very rare and usually occurs injuries. ferred to Mars. and the symptoms — begin to abate at the third or fourth week. exhaustion. varying from a few minutes to a few is clouded. infections. The patients usually retain for residuals of their and peculiarities conduct. there is occasional profuse and distended. suddenly is appear and disappear. is greatly disturbed. can create and possess millions. . the vessels of the the con- head and face perspiration. In emotional attitude there are rapid changes between extreme happiness and profound distress. The height of the attack is quickly reached. Evidences of : congestion of the head are sometimes noticed junctivae are injected. elected President destroy nations. — The Sleep is state of nutrition suffers pro- foundly because of the small amount of food taken and the Occasionally there is a gengreat expenditure of energy.

except in a few cases. The onset is generally gradual.— . as if under constraint. When started for a walk they halt at the doorway or at the first turningAlthough mentally point. actions. are per- They appear formed very slowly. simple retardation. with folded hands and bowed head. which follow acute illness or mental shock. ing to say thought. Simple Retardation This is the mildest form of depression . They fail The tarded . dull and sluggish. hard to remember the most commonplace things. consciousness is unclouded and the environment is correctly apprehended. It is there is a dearth of ideas and a poverty of Familiar facts are no longer at their command. inexpressive tones. . and eating. numbed. to find the usual interest in their surroundings. exhibiting no What initiative and rarely uttering a word voluntarily. retardation with hallucinations and delusions. retarded. and the stuporous conditions. process of association of ideas is remarkably re- the patients do not talk because they have noth. such as walking. undecided which way to go. a sort of mental sluggishness expressing themselves. and explain that they They sit about as if bereally feel tired and exhausted. dressing. Mental processes become retarded there appears gradually . . it is characterized by simple retardation without either hallucinations or prominent delusions. MANIC-DEPRESSIVE INSANITY 299 Depressive States The depressive states are divided into three groups. Customary is said is uttered in low. thought becomes difficult the patients find difficulty in coming to a decision and in It is hard for them to follow the thought in reading or ordinary conversation.

the patients appreciating keenly that they ill. and without retardation at The may expression of emotion. allowing themselves to be fed by spoon. indicating probably that the disturbance intellectual. are a failure in their profession thing . and seem to live from day to day in gloomy submission to their fate. disappears rapidly. even denying themselves Patients fre- and their families the necessaries of quently express a desire to end their existence. by another. unable to comprehend their surroundings or to understand questions. fear business reverses and begin to economize. They are disgusted with every. psychomotor rather than The patients are unable to care for themis They sit helplessly before their meals. when a look of anxiety or perplexity comes over the countenance. but they seldom make a serious attempt at are mentally suicide.300 FORMS OF MENTAL DISEASE In the emotional attitude there is a uniform depression. and holding firmly whatever may be pressed into their hands. ronment have lost religious faith. . The patients then lie in bed perfectly dumb. leaving no memory This form of depression runs a rather uniform course with few variations. is answer questions. some time during the course of the psychosis develop into a condition of stupor. The improvement is gradual. except in rare instances. do not care to live longer. If able to slow. The duration varies from a few months to over a year. The patient sees only the dark side of life. the response is exceedingly When a question not having been readily answered followed. This stuporous condition of the events. Insight is fre- quently present. they are unsuited to their envi. Life has lost its charm . The past and the future are alike full of unhappiness and misfortune. even at quite an interval. They life. the ques- tions may be answered in the order propounded. selves.

and made many their enemies life . in addition to psychomotor retardation and difficulty of thought. and whole has been one long series of mistakes. They accuse themselves of bringing misfortune on others. and may even claim that the scaffold for their People hold them in deriexecution is already erected. They feel great sinners. indulging in all sorts of self-accusations. Their various delusions may become . Others are incriminated by sion. and no more tears. and occasionally even a short period of exhilaration and buoyancy of spirits cases appear after . is Hypochondriacal delusions are prominent their health ruined. They their misdeeds. They claim that they have no feelThey ing. or of causing some great calamity. lowing a period of indisposition. both men and women.MANIC-DEPRESSIVE INSANITY Retardation with Delusions and Hallucinations 301 The second group is characterized by hallucinations and varied delusions of persecution and self-accusation. that they have been The patients are profoundly despondent. tion. fol- The onset of this form is usually subacute or acute. to wander about in utter misery. a few an acute illness or mental shock. and the presence of is sufficient evidence of the last stage of consumpcough a Female patients may complain of being pregnant. they are in the clutches of some malignant dis. have neglected their duties. and will be taken to hell. fear arrest and imprisonment. and are suffering imprisonment. and will be driven into the street with their families. Many. laugh and jeer at them. They have sold themselves to the devil. have never done anything right. feel that they are being watched. ease. different organs are wasting nifies away . cloudy urine sig- profound disease of the kidneys. tumors. no sympathy for others. comuterine of or plain of sexual abuse. have lost everything.

the room is changed. notonous tones.302 FORMS OF MENTAL DISEASE One very common delusion is that everything about them is altered their home is not their own. they are not in the right place. Thought is difficult. and perplexed. The heart has ceased to beat. gloomy. seen when they attempt problem. dition . condition is very often present. They understand questions. and answer coherently but the content of thought and speech shows a constant tendency to revert to their depres. In conduct the psychomotor retardation their slow evident in and hesitating replies to questions. without which die. been removed to can neither live nor they themselves are life. sive delusions. The patients are dejected. have another world . disagreeable odors permeate the room. the and comprehend correctly what tran- spires in their environment. there is almost . The consciousness is patients are oriented. and think only as is of their own misfortune. is they appear utterly indifferent to them. the stomach and intestines are entirely gone. : never will return . The emotional attitude is uniformly depressed. Hallucinations are occasionally associated with this con- groans and moans are heard. and their sluggish and languid movements. Sometimes they lament for hours in moAlthough conscious of the surroundings. and fearful scenes are depicted. for the most part unclouded. yet while admitting recovery from previous similar attacks. and absurd and fantastic. Further. They tire Insight into the to write letters or to think over a easily during visits. terrible apparitions appear at night. changed. They are self-centred. a skeleton. their relatives are gone. they declare that their present condition is so much worse that they can never recover. are but a shadow. and even if their heads were cut off they would still continue to live.

The duration extends from six to eighteen months. of a feeling as if there were weights upon the chest. 303 There is often considerable anx- when the patients pace up and down the room. of — The patients complain firmness. with hallu- a pronounced clouding of consciousness. The sleep is broken and disturbed by anxious dreams. save for the tion. action. The appetite is poor.. the tongue coated. it In the is latter case develops gradually. which remind one very much of alcoholic delusional insanity. numbness in the head. Otherwise the onset sudden. and of palpitation of the heart. The is patients are so absorbed in their delirium that there to external stimuli. The eyes are lustreless. patients attempt suicide. epi- This form rarely appears alone. For them changed in the seems most everything fantastic manner scarcely any response . The course of this form shows variations with partial remissions and very gradual improvement. Stuporous Conditions The third group of depressive cases is characterized by numerous incoherent and dreamlike delusions and cinations. sway the body. and the bowels constipated. Occasionally the There are a few cases which present coherent delusions of persecution accompanied by many hallucinations with clear consciousness. picking at the clothing or rubbing the head. the skin is sallow and without its accustomed Physical Symptoms. psychomotor retardapart. but usually forms an sode in the course of the other forms. The hallucinations play a rather important and persist for a long time. MANIC-DEPRESSIVE INSANITY no independent ious restlessness. or rock uneasily in a chair. There is usually a strong aversion to food.

in a . Besides the pliysical symptoms noted cinations in the other forms. and are made to do penance for the whole world. and passing troops have arrived to Crowds jeer at them.. the resistance to passive movements and peculiar postures. are to be shoved off into space where they will keep falling forever. They do not eat. 30-1 FORMS OF MENTAL DISEASE is being consumed by fire or congealed They themselves are removed from everybody. and the feet. the body of a serpent. Everything about them has a most mysterious aspect they are in the midst of historical personages. and left there alone. Occasionally a few words or sentences are uttered slowly and in low tones. The improvement is gradual. with persistence of halluand some delusions even after the consciousness has become clear. they are attend their execution. betraying their anxiety and fear. extreme constipation. or occasionally diarrhoea. lying in bed thoroughly indifferent only the anxious expression. or they are crowded into a narrow grave from which they can never escape. have been taken up into a cloud and carried off to the farThey thest point of the universe. They have been transformed in a most horrible manner have two heads. is a profound disturbance of nuweight. While in this dreamy state they are closing in . The walls of the room are upon them. with considerable loss of foul odor of the breath. great insomnia. there trition. of an elephant. and are entirely unable to care for themselves. : considerably retarded. made to wear a crown of thorns or are tinned loose to run naked in the street. the whole world into ice. The height of the disturbance is reached few weeks and runs a short course of from four to eight months.

characterized by a maniacal state with undoubted evidences of retardation. exhilarated. and awake happy. questions are not understood unless re- peated with emphasis. A depressed patient may retire and retarded. Simultaneous appearance symptoms characterizes the deep depression there may of maniacal and depressive mixed states. display a poverty of thought and a slowness attention is of apprehension and comprehension. at night dejected niacal patient attempts suicide as a result of depression. These patients. in spite of pressure of activity. or even a whole day. The poor. In conditions of persist a strain of happiness in the emotional attitude and a facilitated release of voluntary depressed patient may smile at absurd remarks impulses. . A in his presence or say something witty ful. called respectively maniacal stupor Maniacal stupor is and stuporous mania. For a few hours. maniacal symptoms. yet they do be made. and of exhilaration in the depressive states. or the active. and even then absurd replies may They are not especially talkative.MANIC-DEPRESSIVE INSANITY 305 Mixed States The the third phase of manic-depressive cases presents a combination of the fundamental symptoms appearing in other two. when suddenly exhibit typical he may the cloud again settles down upon him and he becomes Occasionally a hypomadepressed and retarded as before. maniacal patient . In mixed states there are two groups of cases corresponding to the predominance of the symptoms of one of the states over those of the other. and active. An indication of the close relationship between the maniacal and the depressive phases of the disease has already been demonstrated in the transitory periods of depression in the maniacal. expressing anxiety and fear. boast- may be ill-humored and discontented.

or all of their actions. is Con- sciousness clear. overthrow fellow- smash windows. lead to the suspicion that the patients are deteriorated until at some time or other they giving pertinent and even quick- In emotional attitude they are cheerful and serene. sing and talk loudly and freely. not remain silent for very long at a time. often make One bright and striking remarks. rush about. tricks.306 FORMS OF MENTAL DISEASE Their speech Conversation up. being limited. activity but closer observation discloses their incapacity for any systematic occupation in spite of orderly They show an inclination toward pranks and They hoard up scraps. tear their clothing and destroy furniture. grimacing. may even drag until the patient gets warmed Their manner and conduct may suddenly appear witted replies. perhaps. hours as quickly return to the previous stuporous patient would sit on a settee with downcast coun- . and then always in low tones. pound furniture. pressure of activity is not striking. examination often fails to reveal any undue behavior. These patients are inactive. laughThe ing both with and without sufficient provocation. lying abed most of the time or sitting unoccupied. and only occasionally answering questions. may break things impulsively. and they seem to be oriented. sluggish. and then after a few state. disrobe. and mischievous annoyance of others. to self-adornment. is incoherent and often very monotonous. alert. A superficial . In stuporous mania there is a predominance of stupor over the maniacal symptoms. and pick There is their clothing to pieces. Some entertain a few changing depressive delusions. In the midst of this stuporous condition they suddenly develop great activity. an evident lack of Occasionally they pre- meditation in patients. seldom speaking voluntarily. plunder rooms.

MANIC-DEPRESSIVE INSANITY

307

tenance, apparently oblivious of the surroundings, never

responding to questions or to the
in step to a tune

calls of

nature

:

suddenly
the hall

she would leap up from her seat and waltz

down

which she would hum, but in the course few moments would again return to the seat and assume her previous attitude. It is not usual for such a state to form the picture of the entire psychosis it occasionally appears as an episode in the course of a maniacal attack, but more often forms a part of the transition state between a maniacal and a depressive condition. Other less definitely mixed states are encountered in the transitional period between individual attacks.
of a
;

Course.

— The

course

of

manic-depressive

insanity

is

marked by recurrence of attacks separated by lucid interWith but very few exceptions, following the first, vals.
others recur throughout the
life

of the individual, appear-

ing with greater frequency between the ages of eighteen In a small percentage of to thirty and forty to fifty.
cases, four to five per cent., the attacks

from the

first

pass

directly
larity

from

one into another, sometimes with such regu-

that the

name

" alternating insanity " has been

applied to them, or where short intervals have intervened, " circular insanity." If but one or two attacks occur dur-

ing the

an individual, the separate attacks are in no way essentially different from those recurring frequently.
life

of

Usually the

first

forms the type for the majority of the
is,
;

succeeding attacks, that

the
it

first

being maniacal, the
all

majority will be maniacal
of the
is

seldom happens that

are

same type
suffer

:

at

some time or other a depressive attack
the other hand, one patient during
all possible

sure to appear.

On

life

may

from

forms, from hypomania to

profound stupor.

Where

the

first

attack occurs before thirty years of age,

308

FORMS OF MENTAL DISEASE
especially in

and
first

women,
is

depressive attack

most often depressive. This often followed by one of a maniait is

cal character.

Two

consecutive depressive attacks at the

beginning are rare.

A

first

maniacal attack

is

almost

always followed by
attack.
after

a lucid interval, seldom

by a depressive
until

The mixed forms usually do not appear The two to
single attacks vary in length

two
to

or three attacks of either the maniacal or depres-

sive form.

from a few

weeks

five years, the usual duration being from

six to twelve
increases.

months.

As the

attacks recur, their duration

vary considerably in length, from a few days or weeks to many years, and stand in no definite
lucid intervals

The

relation

to

the

duration of the attacks.

They

are apt,

however, to be longer at the beginning and shorter as the
attacks recur, until finally they

may

disappear altogether,

the attacks passing directly from one into another.

Dur-

ing the intervals the patients are perfectly lucid except in
a few cases where the attacks are long, frequent, and
severe.

The

patients are able to

reenter the family, to

employ themselves profitably, or to conduct business. Even the few who do not thoroughly recover are able to leave the hospital, but are apt to show some restraint, lack of independence, a tendency to be morose, an unusual susceptibility to fatigue, an instability with a diminished capacity for work, or they may be irritable and self-conDuring the interval some of the patients fail to scious. show genuine insight. They realize that they have been " excited and nervous," but attribute it to family trouble and confinement in a hospital. The lucidity of a long interval may be interrupted by short periods of moderate exhilaration, flightiness, and unusual activity, or on the other hand the patients may be unnaturally apprehensive,

MANIC-DEPRESSIVE INSANITY
suspicious,

309

and despondent.

Where
is

the attacks pass from

one into another, the transition
detect states similar to those

gradual, reaching over a
it is

period of several days, during which time

possible to

encountered in the

mixed

forms.

The

transition

vice versa, is

from a maniacal to a depressive phase, or usually gradual, though it may occur during

In this transition the stages of alteration are At first the countenance of the usually quite perceptible. depressed patient becomes more open and the eyes appear
a night.
brighter and the skin firmer and more elastic.
is

The

patient

more affable, shows more interest in the surroundings, The activity, at and expresses a desire for freedom.
first

increasing
all

slowly,
is

now becomes prominent
From
this

:

he

is

busy

the time,

happy, never

felt better in his life,

and everything

pleases.

time the maniacal
at first

state becomes quite evident.

The maniacal patient

gradually loses weight, the pressure of activity abates, he

calmer and more in earnest, his many schemes recede to the background and then entirely disappear. Soon his
is

movements become
less,

languid, he himself
ill

is

seclusive, talks

only occasionally mentioning his

feelings

fortunes.

His countenance

loses its freshness,

and misand at last
unfavor-

we have a

typical depressive state.

Prognosis.

— The

prognosis of the disease

is

able in view of the certainty of the recurrence of attacks

throughout the life of the individual. It is favorable for recovery from the individual attacks, except in a small percentage, four to five per cent, of cases, which from the
While, onset pass directly from one attack into another. that it is sure there will exception, be other with this
attacks and recoveries, the frequency of their recurrence

and the duration of the

lucid intervals is entirely uncer-

;

310
tain.

FORMS OF MENTAL DISEASE

At

present

we have no means

of
it

judging just what

the future course will be.
ever, that
it is

In general

may

be said, howitself

safe to predict frequent recurrence of attacks

with short intervals where the psychosis manifests early and without external cause.

If the onset is previous to the period of involution,

one

There should expect a recurrence during the climaterium. few cases in a only is a tendency to mental deterioration

where the attacks are long, frequent, and severe

;

but even

these patients, in the intervals, are conscious, well oriented, and retain a very good memory. They are indifferent and
irritable,

and very
in

susceptible

to

alcohol,

and may be

deficient

judgment.
;

These defects increase with the

recurrence of attacks
rioration
is

but even after

many

years the dete-

very moderate and can be distinguished from that

of other psychoses

damental
as

by the persistence of some of the funsymptoms characteristic of the disease, such
pressure
of
activity,

distractibility,

retardation,

etc.

Finally, there

are a few

cases,

especially those

with a

greater predominance of attacks of one type, which, after

many

Diagnosis. — There

years, continue

permanently maniacal or depressed.
is

usually

little difficulty

in recogniz-

ing the psychosis, where there has been a previous attack
yet the occurrence of more than one attack
is by no means pathognomonic of manic-depressive insanity, as it may occur in dementia prgecox, especially in the catatonic form, in melancholia, and in senile delirium. A knowledge of the fundamental symptoms of the disease makes it possible to diagnosticate it immediately in the first attack. The diagnosis depends in the maniacal state upon the great dis-

tractibility, little

clouding of consciousness, flight of ideas

with tendency to sound associations, pressure of activity,

happy but unstable emotional

attitude, paucity of delusions

MANIC-DEPEESSIVE INSANITY

311

and hallucinations, and absence of evidences of deterioration; in the depressive states it depends upon psychomotor retardation, absence of spontaneous activity, dearth
of ideas, dejected emotional attitude, moderate clouding of

consciousness,

and absence

of

evidences of

mental

deterioration.
differentiation of the disease from the exhaustion psychoses and from the excited stages of the catatonic and

The

hebephrenic forms of dementia prcecox will be found fully detailed in the differential diagnosis of those diseases.
citement

The maniacal form is differentiated from hysterical exby the presence of the flight of ideas, pressure
and
intractable behavior.

of activity,

Hysterical excite-

ment

subsides

quickly

short duration.

and completely after but very The delirious form may be confounded
epileptic.

with the dreamy state of the
the content of thought
trolled
is

In the epileptic

uniformly dreamlike and condelusions,

by hallucinations and

attitude patients are irritable,

and in emotional uneasy, and ecstatic while
;

the maniac shows fear and rapid changes of emotion with
a predominance of exhilaration.
It
is

more

difficult to distinguish

simple retardation from

the initial period of depression in dementia prmcox.

In

the manic-depressive patient the psychomotor retardation,

with slowness of movement, low tone of voice,
of attention,

difficulty

of thought with sparsity of ideas, slowness of application

and

slight clouding of consciousness, stand

out in contrast to the absence of retardation, freedom of

movements, and thought without consistent interference with the flow of ideas and to the clearness of consciousness in dementia praecox. Rapid appearance of senseless delusions and numerous hallucinations without clouding of consciousness speak for dementia praecox.

312

FORMS OF MENTAL DISEASE
differentiation of the depressive states

The

from demen-

tia paralytica and melancholia have been discussed under

these psychoses.

Acquired neurasthenia is sufficiently differentiated from the depressed forms under that disease.

The mixed
recognition.

most frequently lead to error in their They have sometimes even been mistaken
states

They are to be differentiated from the catatonic condition by the absence of negativism. If in the mixed states the patients struggle,
for the excitement of imbecility.

the cause for

it

lies

in the irritable, fretful

disposition,

which almost always leads to abuse and violence. In stuporous mania the patients pay more attention to their environment, and are biassed in their actions by circumstances, in contradistinction to the sluggish or wilful indif-

ference

of

the catatonic.

They furthermore

display a

poverty of thought and not a stereotyped and senseless
speech production.

The movements

in catatonic patients

are apt to be planless, instinctive,

and with a uniform pressure of movement, while in stuporous mania they are playful and adapted to the environment. Individuals who have suffered from an Treatment.

attack of this disease should be compelled to lead a quiet
life,

free

from

irritating influences.

They
its

are very sus-

ceptible to alcohol,
lously.
if

and should avoid

use most scrupu-

They should be advised against marriage, and,
In patients
reduce the

married, against further child-begetting.
suffer

who

from regular and frequent recurring attacks,

graduated doses of trional or sulphonal
intensity of

may

the excitement, or ward off altogether an

approaching attack.

Berkley recommends for the same
full doses.
it is

purpose atropia given in

In the separate attacks of the maniacal forms

essen-

;

MANIC-DEPRESSIVE INSANITY
tial to

313

remove at once

all

forms of external

irritation,
is

and,

except in very mild cases, removal to a hospital
sary,

neces-

and even the milder forms run a more moderate course under the influence of quiet and well-regulated hospital
surroundings than outside.
to increase

Unrestrained activity tends
is,

the excitement, and there

therefore,

an

indication to limit as
activity.

much

as possible the pressure of

One of the best means of accomplishing this is confinement in bed, especially those cases which are anemic
debilitated.

and

In severe excitement, prolonged
It,

warm

baths give excellent results.

however,

may

be nec-

essary, in accustoming the patient to the baths, to temporarily give a preliminary dose of sulphonal fifteen grains,

or hyoscin hydrobromate
plished, the

j^

to

1
-g

^ grains.

This accom-

warm bath properly applied will

often relieve the
treat-

greatest excitement,

and frequently renders medicinal

ment unnecessary.

When

unavailable, the use of hyoscin

hydrobromate hypodermically or by mouth is an excellent measure for subduing intense activity. After the excite-

ment

subsides, the

prolonged bath, combined with occaall restraint,
is

sional freedom

from

of

value.

In very

extreme excitement with impending collapse, the administration of alcohol, in the form of whiskey or brandy, or

camphor

is

necessary,

and

in or

the
caffein

case

of

coexisting

cardiac weakness,

digitalis

should be added.
necessitate the use
ser-

Prolonged and extreme insomnia
of hypnotics, of
viceable.

may

which sulphonal and trional are most
is
it is

Another important indication
the patients, in which

the manage-

ment

of

absolutely essential

that the greatest amount of tact and patience be used
gentle friendliness at suitable

moments very

often renders
tracself-

what appears
table.

to be a

most dangerous patient quite

This requires that the nurse exercise complete

314
control,

FORMS OF MENTAL DISEASE.
be free from
all all

prejudices,

avoid

all

use

of

discipline,

and above

be

frank and truthful.

The

nutrition of

the patient demands special attention.
It
this.

An
often

abundance of nutritious and easily digested food should
be offered the patients at frequent intervals. requires considerable patience to accomplish
to ascertain

In

severe cases the patients should be weighed daily in order
if

the body weight

is

falling off,

and where

necessary artificial feeding by stomach or nasal tube can be

employed.

It is

very often a

difficult

matter to deter-

mine when the patients are well enough to be discharged from treatment, because of their great importunity and impatience to be set free while some symptoms still remain. One of the greatest dangers arising from an early discharge
is

the tendency to alcoholic indulgence.

A

safe guide for

deciding this question

may

be found in the weight, which

should return to uormal.

In the depressed
or morphia
is

states,

accompanied by agitation, opium
effusions

often indicated to induce quiet (see p. 265).

Evening baths with cold

and

careful massage

may

be used with great benefit.

A

carefully prescribed

good nutritious diet, ample rest in bed, and outdoor exercise, is always indicated. Special attention
routine, with

should be paid to digestion.

All sources of emotional

dis-

turbance should be avoided, such as the visits of relatives,

Attempts to comfort the patient in the height of the disease seem to be useless. In the lighter cases hypnotic suggestion has been used to great advantage in relieving the insomnia, despondency, and disagreeable somatic sensations. The greatest care must be exercised to prevent suicidal attempts, which are
long conversations,
letters, etc.

often to
patients,

be most guarded against at times

when

the

though

still

convalescing,

believe

themselves

MANIC-DEPRESSIVE INSANITY
recovered,
phases.

315

and

also in the transition period

between two

BIBLIOGRAPHY
Kirn, Die periodischen Psychosen, 1878. Mendel, Die Manie, Eine Monographic, 1881.

Emmerich, Schmidt's Jahrbuecher, CXC,

2. 2.

Pick, Circulaeres Irresein; Eulenburg's Eeal encyclopaedic,

Auflage.

Hoche, Ueber die leichteren Formen des periodischen Irreseines, 1897. Hecker, Zeitschrift fur praktische Aerzte, 1898, 1.

Weygandt, Ueber die Misch Zustaende des manisch-depressiven
seines,

Irre-

Munich, 1899.

Hoch, Maniac-depressive Insanity, Reference Handbook of Medicine,
toI.

V, 1902.

or involvement of the coherence of thought. Many consider only the character of the development of the psychosis and early symptoms.PARANOIA Paranoia is a chronic progressive psychosis. clouding of consciousness. It is the careful study of the clinical symptomatology in conjunction with 316 . Others have applied the term to any psychosis in which the predominant symptoms were primary delusions and hallucinations. without marked mental deterioration. or as involving the intellectual sphere alone. These views together with the consideration of the disease process. The many unsuccessful attempts to classify the forms of paranoia according to the psychological symptomatology has usually led to the conclusion that the various transition forms into other psychoses predominate in the clinical picture. or of the emotions without regard to the course and the outcome. account for the use of such terms as periodical paranoia and acute paranoia with recovery. Since the adoption of this application has name by Mendel in 1881 its psychiatrists shown wide its variation. A mental disease should not be characterized alone by the presence of hallucinations or delusions. primary disturbance of the intellect. and pay little or no its out- attention to the course of the disease as a whole or come. occurring life mostly in early adult characterized by the gradual development of a stable progressive system of delusions. This naturally interferes greatly with the integrity of any disease picture. either as a purely affective mental disturbance.

of the cases admitted to insane hospi- tals. however. . and disappointment. The dis- ease begins between the ages of twenty-fiv e to forty. the course and the outcome. — ble pathological anatomical basis peculiar to paranoia. or seclusive. and is is — usually so insidious that the disease before it in existence long During this period it may have been noticed that the patient had changed in disposition. Etiology. especially of malaise and insomnia. t — The are disease is not common. constituting only wo to four per cent. Some show perverted sexual instincts. ities may be recognized early in the patients being moody. bright. and thathe had made indefinite physical complaints. mentions that the most striking pathological sign encountered by him is the abnormal topography of the cerebral cortex. .) business reverses. the intersection of sulci and malposition of convolutions. . entering into many projects which they were unable to pursue successmany show stigmata of degeneration. others have always been flighty. having become somewhat irritable grumbling suspicious. . excessive mental stress. shock. large percentage of the cases. and easily discontented. or a marked aptitude for study or mental activSome have been abnormally ity in special limited fields. such as an acute illness. either con- genital or acquired. J There is as yet no demonstraPathological Anatomy. 1 Berkley. is recognized. very gradual. Exciting fully causes occasionally form the starting-point of the psychosis. Men more often afflicted than women.PARANOIA 317 the etiological factors. dreamy. deprivation. It develops on a defective constitutional basis. defe ctive h eredity existing in a very Peculiar traits and eccentriclife. 1 is The development of the psychosis Symptomatology. extending sometimes over years. which has led to the recognition of the disease picture described here.

by the indifference displayed and the little some ignore them. resultant pe rsecutory delusi ons are constantly increased aggravated. Some patients are able to ignore for a time the apparent indifference of friends. is cannot all be accidental. Any doubts as to an evident purpose in all this are sooner or later dispelled by remarks accidentally overheard. and members of his fraternity of plots. or accidental nods of the head have special reference to themselves. or are shadowing their footsteps. but others become disturbed and suspect a malicious purpose. The wife seems less attentive. much They are mor- bidly sensitive. always fights his cigar or coughs when near them men similarly dressed always meet them near the same corner. sets the patient to think- ing that ful. bill Items in the paper indicate some hints. and careful watching soon satisfies him that he is neglected. intrigue. He leaves his employment. . posters contain some daily passer . considering that such trifles as harmless jokes. or imaginary slight on the part of a it close friend. and often becomes rude and discourteous. He becomes distrust- constantly seeking other evidences of unfriendliness. the children less loving. accuses his friends of slights. and little affairs at home or in the shop cause displeasure and arouse suspicion. and the and Those who conscientiously approach and question friends or supposed intriguers are further alarmed and justified satisfaction obtained sively. and the overseer more stern. holds aloof from his companions and friends. He begins to make complaints. shopmates less friendly. others answer evaTrivial matters which formerly passed unheeded . both at home and at work. smiles. The accidental absence of the morning greeting.318 FOKMS OF MENTAL DISEASE The first symptom to be noticed is that the daily mental or manual labor becomes distasteful. In this way false inter- pretations gradually assume greater prominence.

finds a sufficient cause for her persecution in attempts of her enemies to secure her hard-earned accumulations. While others some find this in property it lies which they really possess. or of a crowned head that he is of Napoleonic descent and lawful heir to the throne. a decayed tooth. the patient asks himself why he is so molested and tormented. is ance of natural baldness readily them out The appearexplained by the appli- cation of electricity during sleep. there delusi ons. napped son of a millionaire. why so many. Sooner or later. finds the reasons for her persecution in her attractive appearance. who had accumulated considerable property by dint of hardest labor. seem directly interested in him.PARANOIA are 319 and absurdly interpreted and enter into the structure of their delusions. and why he is constantly accompanied by a secret Gradually it dawns upon him that he is a kidpatrol. may also appear e xpansive These may be coincident with the persecutory ideas at the onset of the disease. but nations. but more frequently are the outcome of the delusions of _peiaecuiaim persecution lead J^p increas- ing attention which the patients attract. Where the expansive delusions are more directly evolved from the delusions of persecution. not only individuals. and the persistent them to cast about for the reason. or are of noble descent. . or headache are of the regarded as positive proof of treachery and an effort to get way by a slow process of poisoning. a calfalsely all now loused finger. A thrifty Irish woman. . A spot on the coat. in connection with these delusions of persecution. and the desire of eminent men to seduce her. factory employee already approaching the limits of the A cli- materic. which are firmly held and well moulded by a coherent train of reasoning. while conclude that they have been born for a special mission. others still believe that in their personal charms.

which is an essential characteristic of the disease. While it this symptom~is mostly characteristic of paranoia. donna directs her song and the birds chirp when they are near. Then all these supposed facts assume a place in the chain of evidence which confirms their conclusions. another recognizing a striking similarity between himself and the equestrian statue of a famous Others are assured of their high station by the general. In the systematization of the delusions another prominent feature falsification is the frequent appearance of retrospective of memory. indicates that they are under the special guid- ance of God. casting its rays upon them. the orchestra begins to play as they enter the theatre. and becomes prominent when the patients discover its purpose. These delusions may only assume the form of an exaggerated feeling of self-importance. the prima at them. an interesting talker. and built out into a coherent system. The appearance of the sun from under a cloud. are held with great persistency. an ideal gentleman. may result. one once receiving a salutation from the President. both persecutory and expansive. or an individual worthy of great political distinction.320 FORMS OF MENTAL DISEASE while his extensive landed properties are unlawfully used by the government. an excellent teacher. or descendant of Christ. —a considers fine lawyer. All delusions. himself especially renowned in The patient his profession. This explanation first appears in the tendency to find evidences of persecution in many or all the events of their environment. The patients become aware of this in various ways. may also be present in the . deference paid them by every one people bow to them. a social favorite. : their names are in the paper. a direct Finally a change of personality and the patient announces himself as titled.

becoming mute at his entrance. visiting at the house. and later a disguised woman. and solicits his attention. Other evidence is gath- . in reviewing their past life. This incident she now regards as the beginning of years of persecution by the priesthood. derisive remarks by fellowclear evidences of their workmen. or detect occurrences which at the time should have indicated their superiority. find evi- dences of persecution. One patient recalled that when thirteen years of age a priest took from her a book. which some cases has been pronounced e rotic enough to lead to the recognition of an coloring is . or by casting sly glances as she drives by. claim- ing that it was unfit for her to read. and later was chosen captain boys' brigade : of the these incidents at that time should have of the fact that he made him aware was to have been a Another remembered overhearing his famous general.PARANOIA 321 paranoid forms of dementia praecox. the religious sometimes strong enough to establish a religious pa ranoia In the erotic cases the patient usually believes himself the object of admiration by some lady who is attracted to him. or an injury. and in melancholia. a situation The loss of many years ago. who would seduce her and then hold her up as led his an example before the world. who was really which pointed to a noble birth and his displacement by a younger brother. She makes him aware of this by daily appearing at her window as he passes. p aranoia. Here the patients. erotic An element often appears in the delusions. Likewise. Many similar incidents scattered throughout life are pointed his mother. now become persecution by enemies. parents whisper in an adjacent room. all of out as striking evidences which aid in fortifying their sys- tem in of delusions. Another patient class in marching.

romantic. and friends would have him infer. but those of gen- eral sens ibility are q uite frequent. the skin irritated by poisonous powder. for which he seeks medical attendbut he cannot be made to realize the fallacy of his . The on the other hand.. Hallucina- tions of hearing are apt to be the mo st promi nent. such as nervousness. pains in the ance . head and back. — the hair is plucked at flesh night. the pierced by is bullets. Numerous fantastic methods of communicating his love to her are devised. or the countenance transformed by the nightly application of an iron mask. or arranging is her hair differently. an open secret. nature. the patient makes an effort to approach his supHer rebuffs may at first be regarded as posed fiancee. necessary for the accomplishment of her desires. neve r genuine insight into the disease. and even well pleased. she Later may appear to him in the guise of one of his com- panions. but do not play a very important part in the psychosis. indigestion. and them. maintained for years without action at others. from casual remarks. that they are Sometimes this fanciful. Hallucinatio ns are alway s present at some time. At first very indefinite noises annoy them. and rarely persist through the whole course of the disease. dow. laughter from a crowd nicknames are called some one curses below the winfrom adjoining rooms excite The remarks are more often of a depreciatoiy bits of conversation Hallucinations of sigh t are rare. to which she responds by wearing certain articles of clothing. platonic love is . Their mutual admiration publicly regarded as He hears it indirectly referred to everywhere. Later they hear their names mentioned. 322 ered by FORMS OF MENTAL DISEASE anonymous love poems in daily papers. or derisive out. There patient. may complain of all sorts of physical ailments.

are unable to conduct a sucand mode of behavior In cessful business. A ch ange affords only tempora ry to the anxiety. attract attention eccentricities. excessive religious zeal. and at first usually despondent. peculiarities in dress. Not tion to their persecution infrequently the first striking evidence of the disease is a . Frequently they assume the offensive. 323 well retained. or an attitude of self-importance. Later they become seclusive. and fail to support their families. and judgunimpa ired. take the matter of vengeance into their own hands. oddities by their in manner. are shy and excitable. except as biassed by the delusions. is The memory is ment. however. long before the real nature of their disease becomes evident. as suspicious circumstances are soon noticed which leave no doubt that news about them have been passed on from their last situation until finally their existence becomes They become unstable in their living. some. tolerate the perit secution and regard fare. move about in their employ- ment from city to city. proud. the world over. Some of them. They are irri- tated by their persecutors.PARANOIA delusional ideas. reaction to the delusions they attempt to call public atten- known by writing newspaper articles and Very often they apply to the police issuing pamphlets. where they soon detect the presence of their former perseIn this way an cutors. In conduct the patients appear quite normal for a considerable time. iron moulder travelled from San Francisco to Boston in order to avoid the persecutions of his relief trade-union. The emotional rel ation to attitude of the patients stands in direct the character of the delusions. and for protection. leave one shop to enter another. and are again compelled to leave. and dogmatic. as essential to their spiritual wel- All sooner or later become arrogant.

If confined in an institution. provided with the best quarters. but another cross to bear before and the proclamation that they are rightfew patients even consider that they are being treated with the utmost consideration and the greatest attention. the course is sl owly progre ssive with a gradual evol ution of de lusions which are constantly being further systematized and made to encompass new environment. whom he fiancee believed had been poisoning his cattle and bewitching his this reason the . in the he was the secret agent of the French government sent to kill him. the patient may address the President as his father. When once established. Several psychiatrists claim that the course . sister. even a few years.32-4 FOKMS OF MENTAL DISEASE murderous assault upon some one. The paranoiac is for most dangerous of all insane. Tme patient assaulted the mayor of the city for keeping him from his another shot at a passing milkman. when the fellow-patients appear to them only as accomplices placed their confine- there to aid in their discomfort. and usually the disease~has been in progress for some time. before recognition. Some patients submit gracefully to it detention. In accordance with expansive ideas. and granted every possible privilege by those who recognize the great injustice done them. another drew a pistol upon a man with whom he belief that was having an altercation over business matters. A The course of the disease is protrac ted. considering their final rescue ful rulers. Sometimes ment them is regarded as an effort of their persecutors to make their insane. they may for a time ingeniously conceal their delusions until they find evidences of con- tinued persecution in their new surroundings. or millionairess demand access to a whose parents are keeping them apart. The onset is always gradual.

is persistent in the . guished by its A rapid development. but are rarely in a condition to resume their ac- customed occupations. the early appearance of emoti onal weakness. j^*^ prcecox have already^^-*" • K The paranoid forms of dementia been differentiated from paranoia under the former \<P30- disease. and absence of mental de tetion rioration for many years. and phys ical si gns. coher ent thou ght. The conduct of a paranoiac is entirely dependent upon the content of the delusions . the prolonged period of insidious At first there is onset. followed by the perse- cutory period with the development of delusions of persecution with hallucinations. and for many years are capable of consider- and manual. The patients usually are quite orderly. uncl ouded consciousness. both mental at a st andst ill for years. few cases of dementia paralytica and melancholia may Dementia paralytica is to be distinsimulate paranoia. present an u nclou ded consciousness. by Regis called the period of subjective analysis. the charac- co herent. Patients become unable to apply themselves. and less care of In some cases the disease may seem to be themselves. sl ow ons et. he cannot be reasoned with. able labor. while in others partial remissions occur when the patients for a time are able to rejoin the ir fa milies. often associated with a change of personality. and syste matized d elusions of persecu- with retro spective falsifi cations of memory. and finally the ambitious period accompanied by a change of personality.PARANOIA 325 of the disease presents definite periods according to the stages of evolution of the delusions. take less notice of their environment. After a duration of many years there appears a moderate degree of mental weakness. The diagnosis depends upon the teristic.

Archiv Psy. comprehension. an unjust award of damages. The psychosis is of grad ual o nset. . a defeat in court. and usually arises as the result of some leg al inju stice. He reaches a point where he is unable to view the standpoint of any one else with any sense of justice. 1895. aslno case of naturally limited to the to confinement in genuine paranoia ever recovers^ The treatment removal of institution of the disease is irritating influences and an where systematic routine with out-of-door life and ample exercise may ameliorate or ward off the condition of mental weakness. more ra pid ons et (three to attic on- nine months).. or an unfair adjustment of claims. and finally develops an insatiable desire to fight to the bitter end. and his personal belief and desire com- — pletely obscure his better judgment. The melancholiac tude. and even the fundamental principles of the law 1 fail of Hitzig. occasional clou ding of an absence of system in the formation of delusions. He sets aside all business in f. The prognosis of the disease is very poor. while the paretic opposes his retention weakly presents a or intermittently and with some stubbornness. XXVIII. Ueber den Querulantenwahn. 221. and rarely submissive to con- finement . He refuses to settle. Koppen. fear. There are a few cases of paranoia which have been designated by Hitzig as querulent insanity (Querulantenwahn) 1 which deserve a brief description here. carries the case from one court to another. a marked disturbance of the e motional self-accusations. sciousness. loss of property. The statutes appear inadequate. in which the patient has been the sufferer.326 FORMS OF MENTAL DISEASE is prosecution of his ideas. and evidences of mental deterioration within the course of two years.

Failing to appreciate the denounces those bits of needlessness of further struggle. to repeat parts of speeches. Hearsay and knowledge gathered at random are cited as evidence in his behalf. the patient becomes peevish. to present greater deterioration . and who do not side with him. in fact it is Me mory to see is well pre - often surprising with what accuracy he is able to quote from law books. and/ course. The few cases of querulency are apt. is On the other hand. and sometimes written with colored ink. consuls. Answers to these letters only create greater embitterment. and to enumerate various dates. the patient physicians. served. indifferent. and not a few often encouraged in his belief who will testify to his sanity. the irritability] increases. after a prolonged \ / than other varieties the content of speech becomes more and } of paranoia more limite d and somewhat incoh erent. There fact is One seldom misses them no insight into the condition. He cannot abide by the ultimate decision after all the usual means of justice have been exhausted. ambassadors. usually upon a particular kind of paper. but there in even a short conversation. a great tendency to monoto- nous repetitions of th e delusio ns. sometimes even stupid. by the that there are always many men. The patient is irritable and often becomes greatly excited in conversation. and money is squandered in the pursuit of justice to the most extreme limits. His letters are long and carefully written.PARANOIA 327 order to carry on the struggle. solicits sympathizers. is Thought continues coheren t. he writes to magistrates. legislators. Consciousness remains unclouded. . although at the same time priding himself upon his ability to exercise self-control. and finally to the President or foreign rulers.

XXII.. 1891. 2.. Mercklin. 2. S. Archivio italiano per le malattie nervose.2. Schuele. ibid. 1884. Amadei 1. Sander. Westphal. f. S.. Allgem. Griesinger. S.. f. Zeitschr. Studien ueber primaere Verrueckheit.328 FORMS OF MENTAL DISEASE BIBLIOGRAPHY Snell. LI. Psy. Psy.. 387. e. XXXIV. ibid. Zeitschr. L. Archiv Psy. Allgem. LII.. Psy. ibid. 252. f. f. u. Sandberg. Allgem. Tonnini. 1 Cramer. . 148. Die Paranoia. 368. S. 6. Werner. I. Zeitschr.. 1879.

which accompany Epileptic deterioration may appear at any period after the onset of epilepsy. transitory ill-humor (Verstimmung). involving sometimes the physical and somefield. They simulate in this respect the attacks times the psychical ever. and by the presence of peculiar transitory disturbances. A patient seiz- with numerous (one or more daily) and very severe . includes certain per iodical disturbances. and incapacity for valuable production. The and group includes x epileptic and*"hysterical insanities. states (Daemmerzustaende). and to a of less extent memerfx' emotional irritability. but in the intervals a general change of the whole personality is more prominent in the general neuroses than in manic-depressive insanity. evidenced by impahment_of_intellect. are characterized in common by a morbid constitutional basis. of manic-depressive insanity. moral anergy. These latter disturbances. andMreamy epilepsy.' GENERAL NEUROSES The They general neuroses comprise those diseased conditions which are accompanied by functional nervous disturbances. * traumatic neuroses. characterized by a varying degree of mental deterioration. and thus far no direct relation be- tween the number and severity of the convulsions and the degree of deterioration has been established. impulsiveness. howmust be regarded as exacerbations of a permanent diseased state. It also . EPILEPTIC INSANITY Epileptic insanity is a complex accompanying epilepsy.

but by the its great intolerance to use displayed the consequent increased intensity of by epileptics. who averages perhaps only five or six seizures yearly. as evidenced not only by the frequency with which it appears in chronic alcoholism. appearing in eightyiseyen per_cent. abuse of alcohol by far the most important external cause of epilepsy. as malformation or asymmetry of skull. of cases where a complete family history was obtained. and . and deterioration. Even when taken of in small quantities. migraine. of cases one or both This parents had been addicted to the use of alcohol. with . may from prolonged and repeated attacks of stupor." which is characterized by a broad forehead. while in over twenty-five per cent. faulty memory. or We may ^the epileptic physiognomy. powerful influence as mental disorders in the causation of epilepsy in children. Neumann states that in twenty- {hree and seven-tenths per is cent. with profound disturbance consciousness. Defective heredity is the most frequent cause suffer — of epilepsy. mention as evidences of congenital defect various physical stigmata. mental disturbances. Wildermuth considers that alcoholism exerts almost as infantile convulsions. thipk^Ups. alcohol often leads to a characteristic intoxication. and show considerable deterioration. A few cases may present many or all the characteristic clinical symptoms of epileptic insanity without having any convulsions. and especially angry excitement.330 ures FORMS OF MENTAL DISEASE may present only moderate deterioration. hydrocephalus. Etiology. epilepsy had existed in the parents. and the mental symptoms. broad and flattened nose. prognathism. in- frequent and brief periods of excitement while another. microcephaly. Fere notes among progenitors and relatives of epileptics the extreme frequency of headaches.

The numerous scars often found on the head are more frequently the results than the causes of the malady. in fifteen per cent.. There is a wide variation in . particularly after infectious diseases. ~ from thirty to sixty years Pathology.EPILEPTIC INSANITY stari 331 ng eyes in with wide pu pils. — As all epileptics are not insane. it may appear later. In thirjy^four per cent. In i. constitutional defect. lesions of nerves. and nine-tenths per under ten years . On the other hand. Wildermuth gives the frequency as three and eight-tenths per cent. or even sexual The great variety of these causes indicates that they are not actual causes. but rather excitants of the convulsions. injuries are frequently assigned as the cause of and in a certain number of cases a direct relation between them can be traced. from ten to twenty years. mental shocks. Epilepsy often appears for the first time during the period of development. opment childhood and later results from a series of insults in the form of acute intercourse. in nine per cent. after the age of sixty. carious teeth. fright. of cases. possibly in connection with vascular changes (epilepsia tarda or senilis). it is evi- dent that the pathology of epileptic insanity must be based upon that of the seizures plus heredity. in f orty-five and \o-i v-?3 a nine-tenths per cent. and in only thirty-four hun- dredths per cent. and other factors whose nature and influence are as yet not thoroughly known. foreign bodies in the ear. and Heeres as four and two-tenths per cent. from twenty to thirty years . convulsions appear in infan cy. during the period of involution.1 ( fourteen hundred and fifty cases Gowers found the follow- ing results : the onset of epilepsy occurred in twe nty-eigh t cent. or in senility. Head epilepsy. the impulse often being given by puberty or menstruation. while their develdiseases. .

that thirteen due to and three-tenths per cent.. especially from alcohol. If the researches of Krainsky. the assumption may fairly be made that epileptic deterioration depends upon a Igeneral and usually pronounced. called remaining eighty and nine-tenths per cent. of cases " genuine " or idiopathic epilepsy various anatomical — — In the changes are found in the brain. also . cannot be explained on the toxic basis. In senile v ascular changes. Nissl. Bleuler). etc. as porencephaly. lead. multiple tubercles. and sometimes cornu epi lepsy the in isolated foci (Chaslin. Cabitto. and Agostini can be substantiated. as well as cellular degeneration. of his cases were polioencephalitis. and five and eight-tenths per cent. The most important of these changes are an increase of the neuroglia tissue. which probably bear some relation to the clinical symptoms. nausea. neoplasms. This theory receives further weight from the fact that the convulsions are frequently accompanied by symptoms which point to intoxication : as drowsiness. to other gross lesions. and sclerosis of the s enile ammonis (Bratz. due to lesions in the brain. headache. it would seem probable that genuine epilepsy is due to a V&pxic condition arising from faulty metabolisjgiV and that the immediate cause of the convulsions is the accumulation of deleterious substances in the blood. changes is profound disease of the cortexTj The periodicity of the seizures may possibly be explained by the apparent tendency in the nervous system to a periodical reaction to any continued irritation. and in uremia.332 FORMS OF MENTAL DISEASE Wilderrnuth asserts views as to the nature ot epilepsy. malformations. Worcester). are While the exact significance of these unknown. especially in the superficial layers of the cortex. etc. But epilepsy. and from the fact that epileptiform attacks occur in many conditions of chronic intoxication. encephalic scars.

. daily routine. there upon a chronic toxin in the body. rioration once established remains without marked progress for years or even life. is to I be found in morbid condi tions of the nervous Symptomatology. although in a few instances a condition resembling complete dementia may be attained. Orientation is usually normal. where patients practically lead a vegetative existence. in more than one-half the cases intellectual activity is impaired. Indeed. but att ention diverted. and emotional weakness. the storing up of a intoxication. Illusions are quite frequent for a short period before and after attacks of grand mal. epilepsy. is somewhat impaired or . moral. especially anxious and conscious deliria. and are almost invariably of an ecgjtatic or terrifying character. and consciousness is clear except Apprehension is fairly keen for the in the dr eamy states. In all cases of epileptic insanity there is a more or less pronounced mental. There is generally a marked narrowness of the mental states. they are generally of a reli- gious character and are not prominent. found in the intervals. — / though proportionally to a less degree than the emotions In the majority of cases the degree of deteor volitions. tissue. ) these latter facts seem to indicate that the ultimate and characteristic cause of the symptom-complex.EPILEPTIC INSANITY If 333 cerebral changes we should base the known anatomical still remain to be explained the periodicity of the attacks. Delusions are not common except in the dreamy where they are accompanied by or dependent on auditory and visual hallucinations. While a few epileptics may produce permanent and even distinguished mental work. and also the hereditary relationship of epilepsy to other mental and nervous diseases. easily Hallucinations are exceedingly infrequent except in the dreamy When states.

by dint of frequent may be recalled. is always im paire d. is The connection is not lost. The religious content of thought another striking symptom. exhort their fellow-patients. platitudes. proverbs. and develop- ment paths. and coherently their remaining narrow circles of Judgment is invariably impai red in proportion to the amount of mental deterioration. patients are able to express clearly ideas. patients keep in the beaten paths. life. and Their vocabulary may consist largely of set phrases. in which they indulge in praise of self and family. dency to detail and circumstantiality. and the aim ultimately obtained by circuitous experience The narrowness and a of faulty thought due to the lack of new memory naturally leads to a self. or engaging in prayer. the recollection of the general is course of hazy_. the essential points. whether recent_Q£__remote. repetitions. of. however. especially Protestants. Many attend strictly to and a few. Memory extent. etc. with ideas. greater prominence of the This is specially notice- able in the conversation of epileptics. more or less In distinction from the memory defects found in other deterioration psychoses. sometimes to a great While prominent events. New experiences are not readily assimilated or thoroughly elaborated. The true relation of . from the Their narratives are obscured by a multitude of data and irrelevant or unessential accessories.33-1 FORMS OF MENTAL DISEASE li mited ide ation and imperfect association of In conversation or writing there is" a strong ten- horizon. prayer or hymn books. many patients spending a large part of their time in reading the Bible. passages Bible. religious duties. and pay much attention to is personal matters. which greatly impede the progress toward.

and Some patients complain of an " internal the reverse. A man with marked mental and physical defects gravely proposed to study theology and another. as well or think as easily as formerly. and with many tears implores the doctor to send for his brother and Many are very curious and meddlesome. Emotionally. stereotyped lamentations. an in creased irrit ability maniby frequent outbreaks of emotional excitement. morbid and baseless irri- fears of illness or death. . imagines he is going to die. who could hardly name the simplest flowers. the majority of patients show great vari- even though intellect may be fairly well preserved. One patient twice a year spends about two weeks reading the Bible and exhorting his fellow-patients. realizing that they have convulsions. however. however." or fear. the never fully recognize incongruity between grandiose plans and their limited ability. desired to become a florist. Another just as regularly. Many show an extraordinary hope of anguish. often get into trouble through their propensity to interfere with others. finer feelings are generally blunted. Epileptics often show increased irritability. epileptics have some insig ht into their condition. and often the most Patients their senseless and schemes are devised. or tability. A few deny that they ever have epileptic ations. and the priest. seizures. and there exists a rather uniform state of emoti onal in differ- fested There is." An interesting feature of the emotional sphere is the fairly constant recurrence at regu- lar intervals of religious exaltation. as well as sudden alternations from elation to depression. As a rule. ordinarily The ence. and cannot remember . recovery from their " fits.EPILEPTIC INSANITY ideas 335 may be obscured or even fantastic lost. and for a part of this period is so excited and noisy that seclusion is necessary. although in robust health.

and assist in carrying him to his bed. rage suddenly inflict severe and and dangerous even on innocent and inoffensive bystanders. may arise at long intervals — — may justly be considered as an " equivalent. due to irritability or la ck of se lf-control. 1 Morbid and sudden teristic are frequent and characPatients will symptoms of epileptic insanity. attack any one who disturbs them. Some patients display marked sexual excitement.or post-paroxysmal stages. apart from is morbid impulses abovo rules of propriety unless described.336 FORMS OF MENTAL DISEASE and at these times are threatening. They often show kindness and when a fellow-patient has a seizure will run to his aid. more especially dangerous. The wild state of blind rage. loosen his neck band. display any mood but one of placid amiability and gentle consideration. infrequent." These sudden impulses to violence and even homicide render Suicidal impulses are very epileptics especially dangerous. without any provThese impulses are by no means confined ocation. and Epileptics show a some are inveterate masturbators. but between the seizures. or perhaps On the other hand. very profound. where patients run amock. violent. place a pillow beneath his head. and impulses either just before or after a seizure. quarrelsome. as many suppose. especially where the higher physical fair grades of mental and training in are requisite. striking and assaulting indiscriminately every cue in their range. to the pre. there are a few patients who never. usu ally go od. di minished c apacity for ivork. . and observe the ordinary is deterioration to others. These are largely often in a blind injuries. Epileptics as a rule are neat. They may engage with 1 success simple routine for years. conduct. The orderly. and their accomplishment the still more so. is a nerve storm which the characteristic epileptic furor.

consciousness is may last from two to ten returns totally abolished. are apt to slight Their characteristic unfinished. permanent employment. In the former there may be an aura. etc. the follow- ing results were obtained. but rapidly extending over the entire body. 1 *In 1088 observations on male epileptics. but and watched. loss of In petit mal there is a very brief consciousness (usually only one or two seconds). and tonic followed by clonic convulsions. The normal plantar reflex (flexion of toes. occurred in eighty-two cases directly after a seizure and in one hun- hundred three cases . and epileptic deterioration can often be diagnosed by the experienced observer from the peculiar facies and speech.) was present in both feet immediately after clonus had ceased. which may assume the type of grand or petit^mal. An extensor response was found in right or left foot in ninety-nine and fifty-three cases respectively. in forty-five. Their physiognomy is quite typical. which minutes.EPILEPTIC INSANITY occupations. without consciousness in the intervals. or leave it no initiative is required. a fall. the Babinski phe- nomenon (extension of toes with dorsiflexion of ankle) directly after the seizure. but gradually within a period of a few minutes up to several hours. either without slight ones. occurred in one and in one hundred twelve cases one hour later. . usually localized instability usually precludes — at first. followed by a cry. In status epilepticus there may be from twenty to over one hundred attacks of grand mal. that is. where little 337 or unless carefully directed their work. and one hour later in two hundred twenty-six cases. Dur- ing the co nvul sions. The reflexes are ab olishe d during the convulsions. Physical Symptoms. made by the writer. extension in one foot and flexion in the other. The most important physical symptoms in epileptic insanity are the seizures. any convulsive movements or with very which often elude observation. and in some cases are not restored for one or more hours. and a flexor response in right or left foot in ninety-nine and two hundred eleven cases respectively while a mixed response.

and often come on in the morning. The phraseology of the patients is definite. and possibly dipsomania. rarely often complain of heada che. Sometimes the intervals each other. and the expression similar. and the pulse rate increased. are so regular that the time of recurrence can be foretold with tolerable accuracy. These attacks vary in intensity. Periodical Til-humor. recognize the following transitory periodical states. and absent in five hundred thirty-nine cases. Epileptics Organic and functional diseases of is the heart are quite_jTequent. Transitory — In form the separate attacks bear an extraordinary resemblance to The same complaints. : humor (Verstimmung) and B. some this of Somnambulism. or strongly accented. and quarrelsome often commit sudden and unprovoked assaults on the nearest person break glass or destroy bedding and furnifault-finding. and in three hundred thirty-nine cases one hour later. During excitement may be so rapid as to be indistinguishable. and the same impulses recur."anxious delirium. The knee-jerks were active in three hundred ninety-six cases. . the behavior characteristic. dreamy which cases should be included^pre. we can A. A. in ill- On an clinical epileptic basis divisions or forms . awake peevish. teristic. the same delusions. were it not for the fact that a few phrases are repeated over and over again. while their frequent pain amounting to analwounds usually heal rapidly. The plantar reflex was abolished in six hundred sixty cases immediately after the convulsions. irritable.and post-epileptic insanity. and often show an insensibility to gesia.. moderate in one hundred thirty-seven. with drawling. conscious delirium. 338 FORMS OF MENTAL DISEASE speech of epileptics is The often often altered and very characintervals after each phrase. It is a brup t. Patients usually threatening. .^)sychic epilepsy . dred forty-seven cases one hour later. it jerky.

wande7~aimlegsly abou t. — all sorts of flashes of light. peculiar odors. or sometimes a few minutes or even In a short time kill. Abatement is gradual. clouded. but in a few cases may persist for a week or more. speak confusedly^paraphasia). morbid sensory impairment of vision. and imperative impulses. Post-epileptic insanity is more common. collect all obtainable objects. and . Sometimes they display vague hallucinations and delusions of a persecutory character. — which or strange sounds. pronounced dreamine ss lasting for hours _o r days. involuntary or grote sque m ovements. and is often followed by a striking feeling of complacency. preceded by transitory ill-humors. monotonous repetitions of words or phrases. as to strike. are completel y disorie nted. and is charac- — — terized by deep dazed ness after__thg_ seiz ure. this a seizure. In pre-epileptic impressions insanity may arise. even when taken in very moderate quantities. Dreamy States. B.EPILEPTIC INSANITY ture. it may precede in form usually occurs after which case the convulsion rarely last the mental atmosphere. — The essential feature of these interesting and important conditions profound clouding of consciousness. lasting for hqurs__or even_days. While it. indefinite paresthesias. 339 and use profane or obscene language. destroy furniture. individual aura. and the convulbecomes consciousness seconds In a few cases the latter passes over into a sion begins. ideas. and are not to be confounded with the exists. The attacks more than a few hours. or generally clears well-being. Patients do not under stand questions. fals ified when such There may be fixed identifications. is is a more or less Very often they are and in that case there no sharp boundary line between the two. Alcohol may also predispose to them.

act in a mechanic al or au tomatic manner.340 FORMS OF MENTAL DISEASE even drink their urine. during which they may masturbate. They are more liable to occur in patients who have seizures at long intervals. they reaver their normal mental and 'emotional attitude very gradually. etc." or j^ychic epilepsy^ ind epende nt the convulsions. or gaze steadily at one point. In some instances they display a heightened excitement. Patients are confused. committed during these equivalents. and do not reco gnize an y one. no account can be obtained from the patients. and are frequently observed in hospitals. demon- extreme importance of the recognition of psychic The history of previous attacks of grand or petit mal. Mental and emotional disturbances. expose their person. with utter absence of motive or at tempt at concealment. As a rule. present evidences of hallucinations. or attempt sexual assaults. arson. The numerous strate the criminal acts such as theft. periods. is The essential feature of psychic epilepsy the disturbance of consci ousness. to the may appear in of the inte rvallary p eriods. Patients have been known to set fire to their bedding or furniture for such trivial purposes as boiling coffee. These attacks . the sensele ssness o f the actions. in their medicolegal aspect. should make the diagnosis clear. move and often delusions. entirely then called are conditions These ^equivalents. or peculiar positions. but will sometimes replyjnOccasionally they assume fixed coherently to questions. While lively sensory disturbances are undoubtedTy present. assaults. and even homicide. and either complete amnesia or only a very hazy_raeall£ction of what has happened. i llusio ns. even if very infrequent. and and appear to They wander aimlessly about. and are by no means rare. and again a gloomy stupor. very similar above. who have co mplete amne sia of aHj^jat has happened.

and the expression justifies the inference that confused tenona ing delusions dominate the emotional sphere. The ? same attitude is maintained for hours or even days. compose poems. Under the head of psychic epilepsy should be included some cases of somnambulism. Nourishme nt often refused. Patients show absolute indifference to their envisoil ronment. occasionally continue for 341 — seconds or minutes. The eyes may be closed. half-opened. and patients may carry on long conversations. or soreness. as in avoiding obstacles. Movements usually display evidences of automatism. Sometimes intense the eyes are closed. The is r eflexe s are a bolish ed. In epileptic stupor the clo uding of consciousness is and prolonged. although occasionally the demeanor indicates happiness or religious ecstasy. but always as if dre amin g. or the facies dazed or staring. stiffness. Epileptic stupor usually lasts one or tw q week s.EPILEPTIC INSANITY usually last only a short time. Next morning they do not rememb er_what they have done. and themselves. and instinc- tive suicidal attempts are not infrequent. but there may be traces of deliberation and purpose. or transact business. occurring in epileptics. or perform certain mechanical movements. but is in severe cases the course isjonger. and without clear understanding. remain in_ bed. is Recollection of the events largely or completely lostr— Resolution generally grad- . but may complain of lassitude. Patients may eat. sensibility is blunted. either wholly or partially. speak. dis- may make suddeja_impjilsivfi-_jattacks. or staring. and in single cases a tem- porary catalepsy is seen. — but an hour or more. They sometimes show a ctive resistance if turbed. Sometimes higher psychic fields are involved. Patients notice only those objects which are directly in front of them. never answer questio ns.

They run away to escape the horrors which confront them. so that 1 One of my patients in his wild furor always ran up and down the hall. and striking every one in his way. characteristic sensations. may occur independently of seizures. The attack develops suddenly. as cutting up their parents or children. On awakening he remembered nothing of what had happened. flames. but in a FORMS OF MENTAL DISEASE few cases the confusion may disappear in one attacks are repeated and prolonged. . This form is more frequent than Anxious Delirium. but usually gradually. the house is or everything is sinking. their parents are perishing. screaming. with prodigious strength. or by fixed and regularly recurring hallucinations. Apprehension is dulled. as red objects. lasted about twelve hours. and were followed by a profound sleep. are is lost.342 ual. animals. and orientation die. or throngs of people out of the walls or floor. With flushed face. Where — tal distur banc e is profound. strength that it larly every six . but these and the predominant tone Patients are of their emotions is one of fear and dread. and the menday. blown into the air. transports are only transitory. or howling and shrieking. must surrounded by devils. stupor. impelled to brutal and incredible outrages. shooting. either silent. and may be preceded by very brief periods of ill-humor. destroying everything within reach. A recent case died from exhaustion on the ninth day. The hallucinations are usually terrifying patients and delusions must be punished. His attacks recurred regumonths. etc. patients may remain for a long time inattentive and dull. they rage furiously. Sometimes God or Christ appears and carries them in splendid chariots to Heaven . 1 The duration of anxious delirium varies from a few hours to two weeks. Sometimes consciousness clears up suddenly after a long sleep. and numbness. and displaying such enormous required six men to control him. etc. surroundings are changed. who come They wade in blood. stabbing.

a feeling of heavi- ness in the head. despondency. and there separated by short intervals. weariness of increased irritability.EPILEPTIC INSANITY transitory hallucinations. The disposition is irritable. as it presents an apparently paroxysmal and periodical impulse to senseless alcoholic excesses. and normal ideas are There is no recollection of events occurring during the height of the Conscious delirium is a rare form. life. signifi- indecent assaults) without any insight into their Attacks of conscious delirium weeks. delusions. who. desertion. the apprehension sions Patients appear from their conduct to be conscious. Among the prodromal symptoms are noted uneasiness. but the whole demeanor. rebellion. mitted. if closely observed. and occasionally sex- Very rapidly after these manifestations there appears an impulsive and irresistible desire to obtain Some relief. but sometimes elated. 343 mixed together delirium. anorexia. which is found in a " mad rush " for liquor. found himself on the way to Bombay. usually anxious. acts (thefts. insomnia. on suddenly recovering from an attack. Legrand du Saulle reports the case of a Others have com- merchant. with seemingly unclouded consciousness. senseless and even criminal cance. Answers to simple questions are coherent and relevant. discloses some confusion and disorientation. may be a series of attacks Dipsomania in many respects resembles epilepsy. may last for days. . Expansive ideas are not uncommon. while numerous illu- and hallucinations may inspire false ideas of danger. which either fol- lows a seizure or appears as a psychic equivalent. anxiety. in which ual excitement. arson. fear. or even months. but in reality is greatly clouded. in a characteristic manner. and delusional ideas often lead to impulsive acts. patients develop a typical epileptic dreamy state.

that friends should take him to a hospital on the first when in the space of appearance of the prodromes. Convalescence is gradual. while a few cases present symptoms of collapse. which may last for weeks. aggressive. and patients retain only a hazy recollection of a few events of their debauch. on coming to his senses. During these attacks intoxication is seldom complete. gastric catarrh. in interruption — day and night — which they continue without to drink large quantities have spent their and even sold their clothing to obtain means for the gratification of their morbid appetite.344 FORMS OF MENTAL DISEASE they become abusive. There are many transitions or variations from cause. and sometimes accompanied by nausea. and a few perhaps present during life only one instance of an epileptic dreamy state accompanying an attack of inebriety. wine. and often. or spirits. or even years in a few instances. — The diagnosis of epileptic insanity is gen- . two days he would drink several pints of whiskey. Diagnosis. finding himself in After several of these attacks he arranged strange places. but often manifest deep contrition. Some patients manifest a disposition similar to that of epileptics. patients have no craving for alcohol. anorexia. gin. The attacks may recur without any external the characteristic picture of dipsomania. and either totally abstain or drink very moderately. ish journeys. months. accompanied by delirium and hallucinations. present no typical epileptic disturbattacks fall but in their suddenly into a condi- tion resembling inebriety. and an abhorrence of alcohol. noisy. until they last cent. unsteadiness. but consciousness is clouded. Some dipsomaniacs ances. and tremors. and in the intervals. of beer. and undertake foolOne man had attacks once in two years. ultimately becoming completely unconscious.

diversified than that the more which is is always uniform. In hysteria. We from* hysteria. Dilatation and immobility of the pupils. etc. 1897. rap_id_changes of disposition. Westphal. somersaults. lively on the ground. XVII. and dependence on external influences. 1 . is and a prominent pro- more frequent and nounced in epilepsy. usually considered an important characteristic of epilepsy. of_th£_tongue. a limited waywardness. Wochenschrift. serious injuries. oeruentia paralytica. an independent Mental weakness ill-humor. Berliner klin. rolling contractions of the entire body. while in epilepsy there is a rough irascibility. opisthotonus. such as impaired p upillary reflex 1 Karplus. of The developmen t epileptic seizure. have recently been found 1 in hysteria. In epilepsy coming on in middle life. 47. of dementia prsecox. (dramatic movements of expression and passionate attitudes). alternate even in the same attack. which sometimes begins with epileptiform seizures. must differentiate it and the catatonic form is In hysterical insanity cons ciousness turbed in the seizures. and consci ousness is never abolished.EPILEPTIC INSANITY erally easy as soon as 345 we can establish the existence of the characteristic convulsions. influ- The seizures are also specially in duced by external visits. physician's and may be ment curtailed or suddenly ab orted by very liv ely exci te- or strenu ous t reatment. periodicity. Here the consideration of the other symptoms. as mental emotions. tonic and clonic muscular jactitation. ences.. In hysteria we find extravagant_caprices. convulsions of the dia- phragm. we must consider the possibility of dementia paralytica. Jahrbuch der Paychiatrie. . and involuntary less deeply dissee su dden we almost nev er falls . or biting.

depends essentially on the cause of the epilepsy and the time of onset." of the attacks. or perhaps not even one.. clouding of consciousness. and attempts to escape. incoordination. as evidenced by enuresis. of separate attacks of vertigo or syncope. When dependent on gross brain lesions. when only one conill-humor. — This . Special weight attaches to the previous history and the proof assaults. In the latter we find negativism. while there are frequent atrocities. eccentricities. and the Prognosis. or replaced by an " equivalent. and uniformity of conduct. occasional vulsion has been observed during life. 346 FORMS OF MENTAL DISEASE characteristic speech _disturbances. etc.. may be absent. we should be prepared for the possibly gradual development of dementia paralytica. In epilepsy there is anxious resistance with indifference to orders. The diagnosis of the dreamy states. and severe lassitude or headache in the morning. will soon clear and inequality. When. however. recovery is out of the question. the intervals. the crimes committed without motive or attempt at concealment. passive_resistance. periodicity Hence the morbid impulses. a^axiaA up the diagnosis. epileptiform attacks occur at long and are accompanied by one or more of the above symptoms. presents some it difficulties is but we must remember that while the convulsion a very important symptom of epileptic insanity. The epileptic dreamy state has been mistaken for the initial stage of the catatonic form of dementia prwcox. rapid and correct execution of commands. senseless answers. injuries to the tongue. the amnesia. but only a brief syncope. and less disturbance of apprehension and orientation. and rapid course will facilitate the diagnosis. periodical and probable night attacks. with absurd acts. and~~stereatypy.

some recoveries have occurred. In some cases of anxious Conscious delidelirium death occurs from exhaustion. etc. in alcoholic epilep sy treats ucces sful ment is often in effecting a cure. while in some cases may improve sufficiently to go home.EPILEPTIC INSANITY 347 mental weakness often progresses to complete deterioration. dreamy states. and in the interval there is usually some mental dulness with transient Improvement rarely occurs in cases where the ill-humor. 1 A These cases are accompanied by extreme mental dulness. rium is not dangerous to life. especially stupor. As far as life is concerned. after years of epilepsy. with exaggerated reflexes. but. patients On is the whole. as them from the hospital. practically amounting to permanent stupor. The more attacks of furor may occur without any seizures. 1 if recurring at short intervals. spastic gait. result from accidents occurring during the convulthe development of status epilepticus. prognosis of epileptic insanity unfavorable. if they have been at all frequent. but recurrence is common if life is prolonged. In epilepsy arising favorable. or at least great improvement. we must remember that serious and even fatal injuries may sions. Genuine epilepsy m ay disappe ar spontaneously. and in many cases decided and long-continued improvement has resulted. . especially is where the disturbance the largely in the emotional sphere. have occurred. and thus the patient becomes a danger to the community. and patients should be subjected to prolonged observation and treatment before we assume the risk of discharging so. lat e in tife. like anxious delirium. incoordination. the outlook is very un- On the other hand. develop a spastic condition. almost approaching spastic paraplegia. tends to hasten the prog- ress of deterioration. When following head injuries. from or small proportion of cases.

not only for their In all cases where insanity develops in epileptics. even in cases undoubtedly following head injuries. of epileptics die as Worcester found that sixty per the result of their seizures. In cases where there are undoubted cranial focal diseases. as nasal polypi. a long-continued im- provement may result from simple ventilation of the brain by trephining. carious teeth. ir ritation. like. Usually the results are only transitory. On the other hand. which not only impairs the mental and physical powers of the parents. but their offspring. imposes a terrible and unjustifiable burden on To prevent epileptic insanity. antisyphilitic treatment of gummata. without any further encroachment on its substance. excision of scars. — When we consider that nearly twenty-five are descended from an intemperall all epileptics we must urge upon physicians the great importance of combating the use of alcohol. we must begin with the ancestors.348 FORMS OF MENTAL DISEASE c ent. a causative treattried. Treatment. removal of tumors. and the diet carein- fully regulated. and to . per cent. To exert a permanently favorable particularly fluence on metabolic assimilation. ingrown and the should be removed. if injuries or not of too long standing. as ment should be tre phining. of ate ancestry. patients should be committed to a own benefit but that of the community. Any so urces of reflex toe-nails. This experience indicates the continuance or gradual development of a general epileptic alteration in such brains. The nutrition should be fostered by careful attention to the state of the a limentary system. hqspital. and after a long duration of the malady the prospect of permanent cure by excision of scars or removal of fragments of bone is very slight. etc.

It is said that this half the chance of bromin poisoning. has been tried with excellent results. as prohibits meat. potatoes. but less frequent. — and — milk. and he Agostini recommends a more varied thinks a strictly vegetable diet will cause injurious Notwithstanding the various views on on the whole there is a positive benefit in the avoidance of an excessive meat diet. Haig gives practically a^ vegetable diet. In many cases not only do the dangerous ill- humors become harmless. farinaceous puddings. farina. and not merely Every epileptic is in alcoholic epilepsy and dipsomania. and finally . and the secretion of urine should be stimulated by of water or other innocuous remedies. The ki dneys req uire attenof salt may be given. dipsomania. but troubles. The reducti on of salt has been recently suggested. care must be used undue s train on the hea rt. An occasional meal with a small and definite (6-8 grains) amount tion. bouillon. copious draughts to avoid In selectingTorms of physical exercise. and nothing is to be gained from it in any case. and occasional hot ba ths employed to induce perspiration.. not only to diminis h the irritability arising therefrom. very severe mental and emotional disturbance occasionally results from its In use.EPILEPTIC INSANITY 349 prevent the excessive increase of uric acid. ony for epileptics method diminishes by oneAt the Craig cola dietary largely composed of milk. very important to insist more or less intolerant of its effects. and vegetables. this subject. It is .alcohol in all cases. boiled or roasted beef unsalted. upon comple te and permanent ^bstin^m^ejmm. rice. absolute abstinence is the only available remedy. The skin should be kept in good condition. diet. eggs. coffee. chicken broth. stomach to enable us to materially decre ase the amount of bro- mids . etc. tea.

gradually increasing the amount until the poi nt of saturation is is reached. it is is somewhat doubtful. dose. until after due trial we can decide from the general condition of each patient whether or no it mentally. Then the which varies with the individual. In single cases the even returning when regard with occasional sh ort inter ruptions. While preferably in the flpen air. the less irritability. emotionally. and the smaller the dose. in every case. his fits. start They should be given at the in very sm all d oses (6-8 grains) three times daily. since the convulsions are practically safety valves. in plenty of water. should or less gradually until be reduced more we establish a norm w hich can be continued for a long time. advisable. 1 In the writer's experience it has been found that the fewer insane epi- leptics who take bromids. which allow the Unless the cause can be removed. the case as cured. Hence we must not attach too much importance 1 to the curative power of the bromids. not the medicine is suspended. after meals. that in a certain number of cases the seizures cease spontaneously without any treatment. however. vio- . in the present state of it is ister the bromids. their utility elimination of toxins. Nevermedical and lay opinion. perhaps better to allow the insane epileptic to have as they often clear the mental atmosphere. either singly or in various combina- with proper precautions. epileptic disturbances disappear. — — is best to continue their use.350 disappear. at the beginning. if ever. and physically tions. suitable occup ation. to admin- theless. which indicated^ by_th£__di^appearance of the throat reflex. not to recur for years. is a valuable adjuvant. even years. and It we may perhaps must be borne in mind. FORMS OF MENTAL DISEASE In addition to careful attention to the bodily health and avoidance of irritants. innumerable remedies have been used to control or abort the seizures.

fail. lence. 1895. and a simple. compression of the carotids should is be tried. abolition of the reflexes. supplemented by absolute rest in bed. in view of the liability to injuries and the ten- dency to sudden violent impulses. .. every be under constant ^surveillance at _day. and ~*£nem ata of chloral hydrate. Among the other countless remedies employed to control — free the seizures atropia. 3Prolong ed hot bath s are also of value. but may be tried where the latter and strict confinement to bed. cardiac weakness. borax. as evidenced by acne. etc.EPILEPTIC INSANITY 351 Should bro mism occur. and an e limina tive and supporting treatment instituted. times. may be mentioned argenti nitras. impairment of memory. the arterial tension excessively strong . Les Epilepsies. morphia. Finally. and the Flechsig treatment by a regular course of opium in increasing doses. and bromids should be administered. and the use of di gitalis and st rych nin in small and decreasing doses. all these have given none are so generally useful as the bromids. promotion of normal skin action. anaesthesias. 1890. Marinesco et Serieux. Reduction of the number of seizures has not apparently diminished the frequency of attacks of transi- tory ill-humor or dreamy states. the bromids should at once be dis contin ued. status epilepticus is not very frequent in insane epi- When if it occurs. brom-ethyl. digestive disturbances. easily digested diet. all epileptic should anjj. bronchial disorders. noise. The leptics. night BIBLIOGRAPHY Eere. followed by bromid s. Essai sur la pathogenie et traitement de l'epilepsie. While satisfactory results in some cases. and destructiveness there is. with rec tal lavage. stupor. and regular evacuations of bowels and bladder. adonis vernalis. oxid of zinc.

1896. Rivista sperimentale di freniatria XXII. Krainsky. 1899. 267. I. Allgem. Craig Colony Reports. Psy. 1897. L'epilepsie. con speciale riguardo alle psichosi epilettiche. LIV. Brain. Agostini. Spratling. Rivista sperimentale di freniatria XXIII. 36. Haig. Trattato clinico Voisin. f. 612. Zeitschr.352 FORMS OF MENTAL DISEASE dell' epilessia Roncoroni. . Cabitto. 1895.

defective will power. the in- fluence of defective education and training. states. of the patients are disease is More than two-thirds 1 women. that disturbances the one hand. acute and chronic diseases. paralyses. as mutism. shock. convulsive coughs. headache. indolence. and sudden and rapid changes of emotional attitude. Other factors are trauma. individual symptoms may be more prominent. and dreamy states. On have the observations. crises or attacks with a great variety of mental and and of physical symptoms. Sometimes such physical disturbances as chorea. tional basis. upon which there appear. of cases.HYSTERICAL INSANITY Hysterical insanity of is a psychosis arising from a psy- chopathic constitution. talkativeness. Die Hysterie im Kindesalter. and anomalies Etiology. and heightened self- consciousness. convulsio?is. we organs in the production of the disease 1 Bruns. anaesthesias. In children. and attacks of screaming. secretion. as irritability. 1897. undue piety. waywardness. Mental stigmata are often recognized in early life. reflex convulsions. — Hysteria An develops upon a morbid constituequally important factor Defective heredjty occurs in seventy to eighty is per cent. in whom the more prevalent among males. and defective speech have been noted. characterized by great instability the emotions. including dreamy paresthesias. paralyses. 2a 353 . The role played by the disturbance of the female sexual is not clear. with great ease rapidity.

Biernacki. and the dual personality. as well as the removal of the healthy organs. These explanations appear inadequate and inconsistent with our clinical and relation of hysteria to other forms of psychopathic indi- etiological experience. that the disease sometimes appears long before puberty. and further that such reflexes result in movement more rapidly than those which are voluntary and conscious. On the other hand. the disease not an affection of the brain. For these reasons seems prob- able that disturbances of the female sexual organs act only as prominent exciting causes. Pathology. we know that frequently uterine disturbances are present. the vari- ous sensory disturbances. in investigation of the paralyses. primarily. have ascertained by means of ingenious experiments that parts apparently devoid of all feeling can release ideas and move- ments without making an impression upon consciousness. They. Charcot and his followers and many other investigators look upon the disease from the side of the psychical phe- nomena. because they overlook both the inti- mate degeneracy and the apparent psychical origin of the vidual symptoms. may it bring about a marked improvement.354 FORMS OF MENTAL DISEASE do produce severe physical and mental disturbance without creating hysterical symptoms. Janet speaks of a disruption of consciousness in the sense . is Some investigators hold that. and finally that it develops in individuals with normal sexual of these organs organs. may be found in its defec- Vigouroux places hysteria with epilepsy and periodical insanity. and that their relief. judging from his investigations into the condition of the blood. — The nature of the disease is still unknown. regarding them all as due to a gouty disturbance of metabolism. believes that the cause of the disease tive oxidation.

Sollier has recently accepted a partial sleepy state. that sometimes they are not even noticed by the patients. applies in the production of paralyses in the The same field. while part of the brain sleeps. The internal relation between sadness and tears is no better understood than that be- tween fright and hemianesthesia. and. in fact. so in hysterical states. Even clouding of consciousness may be brought about by states of feeling. the fact that the physical disturbances do not always cor- respond to the character of the stimulus or to the content of the ideas. just as hysteria can produce edema and disturbances of the heart's action. yet it seems probable that the increased emotional excitement and the greater prominence of the involuntary expressions which accompany it play an important role in the pro- movement duction of the disease. in which diseased conditions of the body are produced by ideas. a hysterical somnambulism. while it must be confessed that hysteria cannot be entirely explained in this way. who characterizes hysteria as a congenital mor- bid mental state.HYSTERICAL INSANITY 355 that different fields of sensory experience can lose connection with the states of consciousness. Terror can cause a of the bowels and whitened hair. that they can appear in fields not accessible to the influence of the will. . to which should be added the This accounts for statement that these ideas are strongly emotional and sometimes of an indefinite content. motor The shortest and best explanation is that offered by Moebius. and are recognized as physical accompaniments of the feeling. basing his conception on the fact that just as in sleep many impressions influence our dreams and movements without arousing any conscious perception or ideation. These are well-known facts. there are sensory fields which receive and react to stimuli.

356 FORMS OF MENTAL DISEASE is There disease. although the patients appear vivacious and bright upon superficial examination. and adopt peculiarities in dress and ornament. ing disturbances. especially scientific. in reality. symptoms are divided into the The psychical symptoms first described are those characteristic of the psychopathic basis and are continuously present. That which is perceived is not always correctly interpreted. and espeany defects. occupying what many writers call the interparoxysmal period. — The psychical and the physical. In some cases there is a tendency not only to amplify events of the past. tive. during which she knew nothing. This is especially true in the field of religion. the paroxysmal period. but even to distort them by pure fabrications. she never suffered. They are easily attracted by anything new or striking. One patient described in full an epileptic attack from which. They enjoy anything sensational. A few patients show unusual gift Often a striking some fields. It is sometimes . and this is especially noticeable in attempts to elicit sympathy and create sensation. while the dreamy states characteristic of the crises or attacks occupy. although occasionally one-sided. no known anatomical pathological basis for the Symptomatology. — Apprehension presents no many patients strik- are unusually sensi- cially for in They have a keen perception for details. and take pleasure in gossip and in all sensuous enjoyments. in fact. is unimpaired. The memory. Psychical Symptoms. according to them. Startling statements without any foundation are often rehearsed to the physician. is feature lack of sound judgment. and another told of a trance of three weeks' duration. become the clients and champions of the most recent physician.

and may give rise to the sensation of Any genuine complaints are greatly exaggreat pain. The disturbance of the emotional attitude is a most prominent element. and how much due to the subjugation of memory to a In some cases. and may even . which may lead to debauchery. Real pain arising from increase in inten- any cause fails to disappear with the removal of the cause. This increase in the emotional excitaquiet bility is probably a cause of the concentration of thought upon self. but continues indefinitely. nation dominates entirely thought and action without creating the picture of a real delusion. gerated by the imagination of the individual until hypochondriacal ideas are evolved. Frequent and abrupt changes in the emotional attitude are characteristic. and in way the patients become self-absorbed. The more is contemplation of external affairs is disturbed more strongly this by an excitable emotional tone the self. at the next crotchety and antagonistic. and there to is a tendency Occa- show emotional outbursts is at very trivial affairs. Its fluctuation determines to a large extent the whole mental life of the patient. sionally there heightened sexual excitement. Some even the attention attracted to derive pleasure in meditating over their own ill health. no doubt. : One never knows . the imagiall lively imagination. are responsive to everything. .HYSTERICAL INSANITY difficult to 357 say how much is of this is intentional deception. Normal control is wanting : the patients are excitable. In this way hypochondriacal ideas originate and gain prominence trifling feelings of discomfort receive exaggerated attention. are impelled to take a personal interest in everything in their environment. where to find the patients they pass abruptly from a state of merriment into passionate anger at one moment they may be distastefully sentimental.

FORMS OF MENTAL DISEASE The headache. to end their miserable existence. about toward to centre. and receive much company. although it entails some suffering. in of the claim that their suffering is even enhanced continue to enter into the entertainments. frightful dreams. but not without emphasizing their own heroic struggle and martyrlike assaults. the symptoms of which the patients rehearse with great clearness and in all detail on every possible occasion. assassins. submission. any new or striking method of treatment. coin- cident with menstruation or with may be the nuclei from which there arises a malady. by such endeavors. lidism. Occasionally they utter threats of suicide. Very often morbid ideas cause anxiety and despair terrible thoughts constantly torture them . However. will be undertaken for the sake of publicity. — sexual These are depicted on every occasion with great show of emotion. The patients develop a most their disease. and may even stubbornly refuse to help. and claimed to have swallowed several pins. such as tying a ribbon about the neck or jumping into shallow water. finding in feeling of personal responsibility in carrying out treatment. ungrounded fears. and perhaps anaemia. 358 sity. Many spite attend enjoyments of life. they lack all treatment. This becomes the more evident in the failure of cooperation in Although complaining bitterly. sometimes even making melodramatic attempts. remarkable attitude which their whole life seems They become fond of and even proud of invait a source of entertainment. One patient drank a small quantity of shoe blacking. and cannot be satisfied unless they have regu- . backache.. alleged hallucinations. Some patients demand early and constant medical attendance. vertigo. ghosts.

which. but accept the most extreme sacrifice on the part of others as a mere matter of course. Often in going the round of physi- cians they fall into the hands of quacks who pamper and cure. etc. Yet at may be extremely obstinate and headstrong subject in their purposes. visit absolute dependency On the other hand. and ask for many consultations. refusing to take nourishment or perhaps to speak. of there is an increased in to external influences. They are always exacting beyond reason. Some themselves to pain and great discomfort. they are constantly asking for something new. new new clothing. and well-mean- ing philanthropists. This . obtain . They In the domain regularly tyrannize over the family. gratify them by offering some wonderful is how- ever. The patients yield readily to evil. it is not unusual for them to change frequently from celebrities.HYSTERICAL INSANITY lar daily visits 359 the intervals. and deeply patients are markedly The grieved over neglect or lack of sympathy. intimate relations with churches. and rapidly become enthusiastic times they any cause. one physician to another. self-conscious. societies. what they have. different food. dissatisfied with the best efforts of others. and prompt response to hurried calls in In this way some patients develop a state of upon one physician. They perceive with morbid acuteness any encroachment upon their own comfort. and even torture for insufficient reasons. new furniture. and display a corresponding lack of regard for other and common interests. It is often surprising to see how undeserving patients successfully establish usually things difficult to quarters. The insatiable wants of many hysterical patients develop as the result of Dissatisfied with this heightened self-consciousness. who toill gratify the most unreasonable susceptibility demands. is as transitory as it striking in its results.

without sufficient and may even present some restlessness stands out in strong contrast to their physical weakness and they long for adventure. excruciating. inexpressible and in depicting their suffering it is not unusual for them to add color to the description by copiand helplessness. being the result of a sudden outburst of the emotions. .360 FORMS OF MENTAL DISEASE apparently opposite state of the will in reality arises from a pliancy to accidental influences. Their vehemence of expression by no means always corresponds to the intensity of the emotion. The patients characterize their own condition by such expressions as. or of a pleasurable inclination. On the other hand. quence of this reason. lack perseverance. In manner and frank. self-enjoyment One patient. is and They change which rapidly from one purpose to another. they pass much time with trifles. dillydallying with their toilet and personal adornment. Impulsive actions arise from the same source. at others personal fancies. or again silly and sentimental. are weak and easily exhausted. They are demonstrative and often express themselves in the most exaggerated terms. the patients have no disposition for earnest and strenuous occupation. arranging and rearranging pretty ornaments in the rooms. closed with the request for macaroons. and always feel that they must spare themselves. as the latter often fluctuates rapidly from one state to another. The capacity employment is impaired. they are at times vivacious . after filling several sheets of her home letter with for the most horrible self-imprecations. sometimes external sensations. most horrible. The conduct unstable of the patients in conseerratic. In spite of this intense usually remains in misery the thought of evidence. ous weeping or even fainting. at others reserved and bashful.

where the mild cases fail to present the characteristic psychic symptoms. characteristic of all these symptoms that they do not fol- . Physical Symptoms. movements. from which it seems impossible to dissociate the characteristics of the psychic which really form a part of the same disease picIn view of this conception. exists in epileptic insanity. numerous sensory and visual disturbance fits. disturbIt is ance of respiration. localized and general convulimpairment of speech. are regarded of more importance. A difficulty seems to arise in the mild cases. in which there usually a predominance of one set of symptoms. however. disturbances. globus.HYSTERICAL INSANITY 361 These mental symptoms of hysterical insanity give only a general picture of the psychical disturbance. including paresthesia. and anomalies of secretion. anesthesia. aphonia. clavus. hysterical insanity. The basis of hysteria lies in poor hereditary en- dowment and states. a detailed description of which will not be entered into here. in which the neurological symptoms are unaccompanied by the psychic symptoms characteristic of ture. but are only a part of a degenerate state which may or may not be associated with hysteria. terical insanity are — The of physical symptoms of hys- more readily recognized. A similar condition. choreiform sions. contractures. hyperesthesia. singultus. it is impossible to distinguish between the hysterical and the degenerate states by neurological data alone. obstinate vomiting. and naturally These functional disturbances. defective development. . There can be no doubt but that characteristics of degenerate states appear in various hysterical manifestations. fainting loss of appetite. paralyses different limbs. cases always present their is Individual own peculiarities. Some really investigators claim that these psychical symptoms have nothing to do with hysteria.

to prick the gums in make bloody sputa. and which tends to substantiate the idea of feigning. take the place of. quietly with relaxed limbs. only to reappear as soon as their illness confronted by the physician. of may lie either follow. in order to convince the physician that the bowels are occluded. Contractures or paralyses may be made to vanish by firm pressure over the ovaries or in the hypogastric region. or by an unexpected dash body. may be immediately transformed into an entirely different individual by a sharp command. which of consciousness. persistence. But this transformation is usually short-lived. Of the transitory psychic disturbances the dreamy are the most prominent. ter- minate in. and departure upon psychic Hernicrania or convulsive movements can often influences. new environment. A prominent characteristic often encountered. occasionally The patients . or some sudden freak. Patients of cold water upon the face or who for years have been bedridden. in the belief that there is is referred to or is when One further encouraged much dissimulation by the efforts of the patients to produce ulcers. or be interrupted by a convulsion. would certainly order to We be short-sighted if we did not see in these premeditated actions the expression of a disordered mind. states These are characterized by a longer or shorter marked clouding duration. is the disappearance of the symptoms when the patients are free from constraint. but are dependent in their appearance. be made to disappear by pressure upon the eyeballs. and to devise means of removing the feces unobserved. reduced to a skeleton by fasting and secretly inflicting wounds upon themselves to incite sympathy. and the patients return either to their former or still more distressing conditions. believing themselves unobserved.362 FORMS OF MENTAL DISEASE low anatomical and physiological rules.

HYSTERICAL INSANITY
showing a slight tonic
erally.

363

rigidity, breathing quietly,

and with
lat-

a slow pulse rate, the eyes turned upward or rotated

They

are irresponsive except to a powerful stimu-

lus, such as an electric shock or sudden terror, which sometimes entirely arouses them. Such a condition, interrupted by occasional convulsions and short lucid intervals, during which food can be taken, may last from a few

hours to three weeks.

Sometimes the dreamy state simulates ordinary sleep, when the patients become drowsy and lie down, the eyes close and limbs become relaxed, as in a profound sleep, with deep and regular respiration. It is usually of short duration, and the patient awakes gradually with no recollection
of the interval.

These attacks form transition states into somnambulism, which occurs during the natural sleep of hysterical patients. The patient leaves his bed, wanders about the room, opens the window, and does many peculiar acts, all

Sometimes he destroys later he clothing, hides objects, or sets fire to furniture returns to his bed, and arises the next morning with only
of
;

which are well coordinated.

a confused recollection of what has happened. Similar attacks may occur during the daytime, either independently
or in connection with a convulsive attack, a
or crying.
telligibly to
fit

of laughing

The

walk about, muttering uninthemselves, oblivious to the environment, and
patients then

not the least distractible, although able to avoid obstacles.
It
is

very

difficult to

arouse them from this state, even by

the application of powerful electrical currents.

Another form of
attack.

the

dreamy

state

appears in connec-

tion with the delirious excitement of a severe hysterical

There

is

a marked clouding of consciousness with

many

hallucinations.

The

patient

is

transported

into

36-4

FORMS OF MENTAL DISEASE

beautiful surroundings, has visions of heaven, sees

God

and the

angels, or undergoes frightful experiences, endur-

ing the agony of a public electrocution, or of slaying a dear friend. While in this state his manner, expression,

and movements are indicative of joy or agony.

One

of

my

patients in sucb a state of ecstasy greeted the physi-

cian as

John Ruskin, and another as the Apostle
officers,

St. Paul,

describing the beauty of her surroundings with great fer-

vor

;

another ran to escape a posse of

who were

in search of her for the killing of her sister.

of the

In the younger patients there appears still another form dreamy state, in which the clouding of consciousis

ness

moderate, and does not prevent a recognition of

their environment.

The

patient usually exhibits a happy,

unrestrained mood, sometimes with

He

performs

all sorts of foolish,

imitates the cries

marked silly behavior. wanton pranks, screams, and behavior of animals, and scrambles

about.

The

real morbidity of this apparently conscious

behavior becomes evident when, as occasionally happens,
it is

suddenly terminated by a light convulsive seizure,

and then, without memory of the foregoing behavior, the
patient passes into a short period of depression.

The memory
onset,
is

of the events during these different

dreamy

states, as well as occasionally for

events just prior to the

abolished.

always much confused, and sometimes completely In some cases there are encountered examples

of a sort of dual personality, in

which the recollection

of

only during subsequent ones, it being completely lost in the interval. It also may happen
that during an attack a particular period of the patient's
life
is

previous attacks occurs

lived over again,
states.

similar

to

experiences

in

the

hypnotic

Such alterations in personality

arise

only

under the influence of autosuggestion.

HYSTERICAL INSANITY
There
still

365

remains to be described mental disturbances

of shorter duration occurring during the course of hysteria.

These states are characterized by a gloomy and anxious mood, sometimes accompanied by delusions of self-accusation and indefinite hallucinations. Conditions of excite-

ment arising as the result of jealousy, more frequently appear in the form

spite,

and the

like,

of

passionate out-

breaks with violent abuse, and sometimes a tendency to
destroy objects, or even to smear themselves.
ally pass off in a few hours.

These usuin con-

Sometimes they recur
is

nection with the menses.
Course.

— The course

of the disease

usually protracted,

sometimes extending over
cially,

many
is

years.

In

women

espe-

the onset of the disease

early, frequently appear-

ing at the age of puberty.

In contrast to the prolonged

course of the disease, the individual
of the most
pidity

the greatest variation in appearance and prominence.

symptoms may show One

marked characteristics of hysteria is the raand abruptness with which the symptoms change. Usually there is a series of attacks which last but a few hours or a few days. Yet when one considers depressed, excited, and dreamy states, and physical disturbances, there
is

usually a variegated picture extending over considerable

time.
is

The

course of the disease in children and in
little

men

apt to be far more uniform, with
Diagnosis.

variation of the

individual symptoms.

— The diagnosis
and

is

far

more

difficult in

hys-

teria in the male,

especially in differentiating the

constitutional psychopathic states.
is

In the latter the course

more uniform, and the dreamy states and various physisymptoms are not encountered. The traumatic neuroses are characterized by a far more uniform development. In differentiating congenital neurasthenia it must be rememcal

366

FORMS OF MENTAL DISEASE
it

bered that

presents only psychical symptoms. The differentiation from epilepsy has received sufficient consideration

under that disease.
Prognosis.

the prospects are good for the disappearance of the several attacks, it is not as favorable for the future of the patient, who is very apt to suffer from a recurrence of the same, or other hysterical symp-

— While

Hysteria in children is decidedly more hopeful, as the symptoms usually disappear with development, leaving perhaps only a weakened power
toms,

on

later

occasions.

of psychic resistance. effected

Occasionally remarkable cures are
of prominent exciting causes, as

by the removal

and with hysteria hypopatients male improper hygiene. In chondriacal complaints is resistive to all modes of treatment. The disease, developing as it does upon a Treatment. psychopathic basis, demands prophylaxis in the way of care of the pregnant mother, and careful supervision of
diseases of the sexual organs, injurious environment,

the education and training of children of psychopathic
parents.

The pregnant

neurotic mother should avoid

all

forms of excitement and sources of fear and worry, and conform as closely as possible to a life of mental equanimity.

The

child,

especially

if it

shows a tendency to

insomnia with night terrors, or restlessness and evidences
of unnatural excitability

and precocity, must be removed

from

the presence of a hysterical mother,

who

is

naturally

least fitted for its training.

Such pernicious environment, where the child is subjected to emotional outbursts and fits of temper, and besides must witness other hysterical symptoms, has an indelible effect, particularly in the formative period between the fifth and twelfth years. Relieved of such surroundings, the main object in the education should be the development of physical strength

HYSTERICAL INSANITY
and
vigor,

367

and the maintenance of an effective state of nutrition. For this purpose, plenty of out-of-door exercise, with an abundance of sleep and wholesome diet, must be prescribed in connection with a discouragement of all elements of precocity in the mental, moral, and sexual life, and inculcation of self-control and the nobler sentiments. The same care must be continued during the period of puberty and youth, but should include advice in relation to sexual matters, sentimental love affairs, and
later to the assumption of the duties of early married
life,

especially sexual relations.

In the treatment of the disease

itself

the element most

essential to success lies in the personality of the physician,

who must

the cooperation of the

and secure Except in the lighter cases, it is of first importance to isolate the patients and establish a suitable routine in the mental and physical life, thereby removing from the environment the disturbinspire the patient with confidence,

family.

ing factors which have always been a source of annoyance,

and have acted as exciting

causes.

This isolation,

although best carried out in a small, well-selected sanitarium, under the direct supervision of a physician, can

be accomplished, with the aid of an efficient nurse, at the

home. At all events the patient must be given over entirely into the hands of the physician, who establishes confidence and control, not by harsh and dogmatic opposition, but by gentle persistence, in which he must combine firmness and even boldness. This accomplished, he is in a position to bring about great improvement, and often recovery, by simple remedies. Attention should be directed to any
possible organic disturbances in the stomach, intestines,

kidneys, heart, lungs, and sexual organs.

Iron should

be prescribed in

anaemia, and

restoratives

employed

in

368
conditions
of

FORMS OF MENTAL DISEASE
emaciation,
as

well as bitter

tonics

for

anorexia.

the other hand, mechanical therapy must be relied upon to produce the best results. Of the mechanical

On

measures the most important are hydrotherapy, electricity, massage, exercise, and employment. In the use of hydrotherapy Collins regards the tonic bath the best, in which
the water, at a temperature varying from fifty-five to sixty
degrees
is

applied under from fifteen to twenty pounds

pressure for from four to five seconds, followed by a Fleury

spray of eighty degrees and similar pressure, for one to two seconds. In the use of the bath hysterogenic zones must be protected. The reaction should be facilitated by passive movements, walking, or gymnastics, for one half-

hour following the bath.
produce the desired
suggests the use
desirable,
effect,

Where
or
is

this

bath
It
is

fails

to

not well
spray.

borne,

he

of

the

Scottish

always

when

possible, to avail

oneself of a hydriatic

institution for

these

purposes.

The treatment can be

accomplished, however, in the house supplied with water

under

sufficiently

detachable hose and a tube.

high pressure by the simple use of a This should always be under

the direct supervision of the physician,

who
is

will find

it

necessary to vary the details of the treatment according
to individual
cases.

When

the

bath

not accessible

the drip sheet

may

be used, the description of which

may
is

be found under the treatment of acquired neurasthenia.

In the application of electricity the faradic current
of

most service

in

improving the nutrition and in

reliev-

ing angesthesia and hyperaesthesia.

The
one of

daily routine of the hysterical patient should be
activity,

alternating

with rest and relaxation,

including massage,

gymnastic, and out-of-door exercise,

HYSTERICAL INSANITY
combined with some sport which tends to increase
reliance.

369
self-

There are a few cases which require surgical treatment
for the alleviation of organic disturbances in the

sexual
disease

organs, especially

where the symptoms
definite

of

the

seem to bear a

relation

to the

menstruation.
the gen-

Removal
eral

of slightly diseased or

even normal ovaries have
cases,

produced improvement in a few
verdict
of

but

it

is

to-day that

this

drastic procedure

has

more often been
discarded. 1

of detriment than benefit, and should be

Hypnotism
tible to

is

of limited value, because those suscep-

hypnotic suggestion are apt to be influenced by
to be presented.

any powerful suggestion that happens
sirable

Furthermore, hypnotic experience brings about an unde-

dependency of the patient upon the physician, which makes impossible an effective subjugation of their own wills in the strife with the morbid influences. The

more easily autosugand the quicker the efficacy of the hypnotic suggestion is nullified by other and opposing ideas. In mild cases, and especially in children, suggestive therapy is of considerable importance in overcoming individual hysterical symptoms, such as paralyses, sensory disturbOn the other hand, simple suggestion ances, and tremor. is a therapeutic measure of great value in every case, and
greater

the influence exerted, the

gestions arise,

often suffices for the complete disappearance of paralyses,
contractures, aphonia, etc.

In the treatment of the hysterical attacks, the patient can often be restored to clear consciousness by a brisk command, or, if this fails, by a dash of cold water upon
the face, by the electric brush, or pressure over the ovaries
1

Angelucci, e Pieracini, Rivista sperimentale di freniatria XXIII, 290.

2b

370

FORMS OF MENTAL DISEASE
In very severe cases

or upon the hysterogenic zones.
inhalations of chloroform

may

be necessary.

BIBLIOGRAPHY
Moebius, Schmidt's Jahrbuecher., 199,
Beitraege,
Pitres,
I.

2,

S.

185;

Neurologische

Lecons cliniques sur l'hysterie

et l'hypnotisme, 1891.

Gilles de la Tourette, Traite clinique et therapeutique de l'hysterie,

1891.

Janet, Der Geisteszustand der Hysterischen, 1894.
Sollier,

Genese

et nature

de l'hysterie, 1897.
3.

Ziehen, Eulenburg's Realencyclopaedie,
Collins,

Auflage.

Treatment of Nervous Diseases, 1900.

TRAUMATIC NEUROSES
Traumatic neuroses
is

the

name

applied to a

symptom

complex arising as the result of trauma, characterized by a gradual appearance of numerous motor and sensory symptoms and mental depression of prolonged duration. The trauma may occur in the form of fright, intense anxiety, a fall or an accident, especially an explosion or a
railroad accident.
first recognized and well deby Erichsen in 1886, but it was not until the work of Oppenheim and Struempell appeared in 1889 that the disease was clearly differentiated and received its present name. The recognition of such a disease has always met with more or less opposition, especially from the French writers, and more recently from Schultze, Hoffman, and

Cases of this sort were

scribed

Mendel,

who maintain

that the disease

is

either hysteria

or neurasthenia of traumatic origin.
Etiology.

— At present
is

there

is

of the pathology of the disease. consider that there

no adequate explanation Westphal and his school
basis, to

an organic

be found in

changes of the central nervous system.

Charcot regards

the disease as closely related to the hypnotic conditions,
because the disease picture wholly resembles the picture
of a firmly rooted autosuggestion.
of the disease
is
still

The

psychical origin

the generally accepted view.

This

view

is

substantiated by the fact that the neurosis some-

times appears without

known
371

injury, as

when

following
if

fright or slight injury not received

upon the head ; and,

An equally important factor in the minds of some investigators is the psychical influence of membership in an accident insurance society.372 FORMS OF MENTAL DISEASE received in an extremity. which may extend over considerable time. injury. pain Added to the emotional disturbance over the for the future. when they improve rapidly and often entirely disappear. would seem to verify Experimentation upon test animals. of possible indemnities and suits for damages. but may be general. the manifestations of the disease are not necessarily limited to it. in this supposition. a tendency remain incapacitated longer than necessary. to and tutional basis. Symptomatology. there also appears and anxiety a desire to obtain as large damages as possible. in which alcoholic intemperance plays a considerable role. and consist chiefly in a condition of despondency . as very frequently tween the accident and the appearance of the first symptoms. At is any rate the symptoms regularly worsen until settlement reached. Another element of importance is the defective constito overdo misrepresentations. elapse be- the time of the accident should be regarded as the cause. and even months. which definite pathological lesions in the neurones can be produced by concussion without severe injury. In cases where these factors exist the neurosis seems to run an unfavorable course. in the course of symptoms develop gradually a few weeks or months following the — The shock. It is a question whether the emotional disturbance at weeks. prevent the rest and quiet which are always essential to improvement. In cases following head injury some contend that a delicate pathological change occurs in the cortical neurones. while anxiety about the trial and the uncertainty of the outcome.

plaints to the contrary is good. Sometimes compulsive ideas and agoraphobia appear. laying stress upon their " hard luck. and always feel embarrassed by a sensation of anxiety and inward oppression. fear and to loss of the 373 power of both physical and mental resistance. — The sleep is . apprehend with difficulty and take little interest in the Thought becomes unusually uniform and sluggish. sensitive. Mental impairment. exhausted.TRAUMATIC NEUROSES with anxiety. The patients become quiet. The capacity for work is hampered by hypo- chondriacal notions and the numerous nervous complaints. and hopeless future. are always tired. dreamy states or acute hallucinatory excitement. and easily thrown into a state of perplexity or confusion. The patients cannot rid themselves of thoughts of the accident. which the patients refer to over and over. which may lead to passionate outbursts and even suicidal attempts. environment." present deplorable condition. and unable to work. In emotional attitude they are very irritable. The memory in spite of comif one makes allowance for greatly the lack of interest in the environment and the faulty attention. They show a tendency to observe carefully everything about their physical condition which may have had connection with the injury. noticeable especially in the inability undergo strain. and believe that they have been severely injured. and often describe in detail. and centres about the accident. but hypochondriacal ideas are apt to be mor« prominent. are unable to express themselves with perfect coherence. because they are not the same. is usually due to genuine head disturbed by anxious Physical Symptoms. depressed. The psychical symptoms here enumerated usually do Occasionally there appear not become more prominent. injuryif present.

also. disturbance of gait and speech. vertigo. difficulty of urination. especially of the fibrillary often present. such as areas of analgesia.374 FORMS OF MENTAL DISEASE is dreams. The sensory disturbances. The pain. slowness and uncertainty of movement. is persistent and troublesome. loss of strength. and difficulty of hearing. poor. The paralysis almost always occurs on the same side as the accident. in which the facial cular exertion. and is frequently accompanied by contractures. and dermography. and especially of paresthesias and pain in parts of the body. as localized blushing. being either general in character. pressure on the painful points. type. paralyses. or involving muscles of the paralyzed part. Of these hyperesthesia is the most frequent. There is often an acceleration of the pulse and sometimes of respiration following emotional disturbance. both subjective and objective. which may have been injured at the time of the accident. All of these disturbances are to be dis- . Besides this may be ringing in the ears. Vasomotor disturbances are encountered. and some tremor. ysis The paral- may be either of the form of hemiplegia or para- and hypoglossal nerves are seldom included. constriction of the field of vision. also increase of the tendon reflexes. and sometimes obstinate vomiting. and the nutrition becomes im- The patients complain of various sensations in the head and back. which is usually the most prominent symptom. Some cases present objective symp- toms. convulsions are Localized muscular spasms and much more common. or musplegia. may be produced in the same way. or even epileptiform attacks. palpi- tation of the heart. are usually in the same side of the body as that on which the trauma was received. Occasionally. hyperesthesia. is Tremor. and may lead to immobility of the there parts. cyanosis. the appetite paired.

galvanization of the head. little and the absence value in establishing a positive knowledge of the existence of a psychical disorder. the The disease may be distinguished from hysteria by the uniformity of the symptoms patient a does not present a variegated change of symptoms. the constricted of galvanic excitability. changing condition. To this Friedmann adds the little resist- further characteristic that the patients have ance for alcohol. Unfortu- symptoms. — The diagnosis is not only difficult. is .TRAUMATIC NEUROSES 375 tinguished from those accompanying organic disturbances in the brain by their broad extent. the increase of tendon are of reflexes. Diagnosis. favorable course. though a similar uniformity in the symptoms may exist in male hysterical patients. but in sometimes impossible. It is useless to attempt to unmask deception by the presence The detecof any one symptom or group of symptoms. Fear of deception. There is not the same pliancy. pronounced alterations of disposition. always over-estimated by the physician. however. and the fact that they worsen under the influence of emotional and physical disturbances. given case. expect to encounter characteristic hysterical attacks and In distinction from the constitutional psychopathic states the psychosis has a more or less sudden onset. depending upon an injury. The nately greatest difference of opinion exists in reference to its the frequency of simulation and the various objective detection. yet in this respect they remind one of a few hysterical patients with a persistent autosuggestion but even here we would . caprice. nor are the symptoms as transient as in hysteria. field of vision. and runs a more dreamy states. and desire for undertaking something new. and compression of the carotids. the acceleration of pulse.

for example. cially fatigue. among these there are some with a long course and an unfavorable prognosis. and hyption frequently serves to bring about great tution with the opportunity for notic suggestion. electricity. the susceptibility to framing. as well as dietetic regimen. or in the presence of general arteriosclerosis. massage. Treatment. Recently the attempt has been made to prove some of symptoms by means of psychological tests . The prognosis is less favorable where there are pronounced focal symptoms. klinischer Vortraege. Auflage. exercise. BIBLIOGRAPHY Oppenheim. It often happens that the symptoms of the disease disappear rapidly as soon is settled. — The lighter cases of traumatic neuroses which appear soon but even after the accident may improve rapidly. In all cases there should be an application of hydrotherapy. F. employ- ment is of the greatest value. may end in recovery or great improvement. Next to this. or even a few years. Schultze. 14 (Innere Medi- . Die traumatischen Neurosen. Yet the duration of many months. Sammlung 2. A residence in an insti- as litigation employment and distracimprovement or recovery. and espe- Experience with many normal persons of different grades of education in these particulars gives the necessary basis for the decision. as. the power of apperception. N. or as soon as the patients are compelled to go to work again.. diminution of the ability to figure. 1892. — The first indication is to dispel as far as possible all ideas of litigation. Prognosis.376 FORMS OF MENTAL DISEASE must depend upon the conformity picture to one of the of tion of simulation the whole clinical known disease symptom the groups.

f. 49 u. Deutsche Zeitschr. Unfallheilkunde. 1896. 445. Nervous Diseases. Euerstner. f . 6. No. Knapp. 1896. Struempell. Nervenheitkunde. 6) . 5 u. Die Beurteilung der Nervenerkrankungen nach Unfall. 10.. Monatschr. 50. Saenger. .TRAUMATIC NEUROSES cin. Dercum. 1895. Muenchner medicinische Wochenschr. 1895. S. 377 I.

is always present a perversion of the tone of and a greatly increased sense of fatigue. demand frequent rests. insomnia. While the patients are capable of taking up a piece of work with intelligence and skill. with- out involvement of intellect or consciousness. 378 . depressed emotional attitude. compulsive and impulsive insanity. because of resulting headache. distractibility. At the same time there appears a mixture of the normal with the abnormal state. the fundamental common and will present a morbid misdirection of thought. feeling. and the sudden unwarrantable changes of disposition and peculiarities of on the other. actions CONGENITAL NEURASTHENIA Congenital neurasthenia is characterized by a perverted tone of feeling. which gives one the impression of disproportion and distortion. or general malaise. they tire quickly. seen in the inconsistency between the clearness of thought and insight into propriety on the one hand. and con- symptom is to be found in a continuous morbid elaboration of normal stimuli. increased sense of fatigue. and in trary sexual instincts. which include congenital neurasthenia. They develop upon a psychopathic basis. indecision in conduct. throughout life.CONSTITUTIONAL PSYCHOPATHIC STATES In these psychopathic states. and are quite unfit for steady application to mental or physical work. There is a tendency to display hypo- There feeling. Physical stigmata are common.

easily discouraged. yet not infrequently happens that they make attempts at suicide. and they the future. no striking disturbance the consciousness remains unclouded and there is coherence of thought. Very often all sorts of nervous complaints interfere with their ability to work. CONSTITUTIONAL PSYCHOPATHIC STATES chondriacal whims. and fear the outbreak of some disease. so 379 in- The distractibility trifling is greatly that even the most interrupt affairs in the surroundings may and is interfere greatly with systematic work. They may have always been especially susceptible to the and misfortunes of life. They are cares.. feel that they are of little use in the world. take little or no pleasure in any occupation. They are very deliberate in the con- sideration of all circumstances and possible results. In and show a certain uniformity and lack it. creased. Sleep is usually much disturbed. Some patients are constantly thinking of death and are always prepar- ing themselves for earnest Though they may not seem it in about it. or that some will befall them. are nervous. Some are always encumbered with the feeling ill that they have done something wrong. Present pleasure is always clouded by past sorrow or the troubled fears of Any undertaking dismays them. The patients often appreciate their unIn the field of intellect there fortunate condition. such as pressure and pain in the head and peculiar sensations in all parts of the body. Upon the basis of congenital neurasthenia there sometimes develop conditions of pronounced depression. sorrows. actions they exhibit a tendency to great precision punctuality in little things. Their actions also of freedom. espe- . sick. In emotional attitude they are oppressed and sorrowful.

is very prolonged. until finally a continuous morbid condition with little varia- there tion. is dis- gruntled disposition. distrustful. with retention of consciousness and good insight. such as pressure about the heart. and stiffness in the legs. lead- ing at times to attacks of blind rage with complete loss of under the influence of alcohol. This condition is one of simple depression without hallucinations or delusions. discomfort in the stomach. self-feeling Here there usually a heightened selfishness. lasting from a few to several years. very tractable. in Congenital neurasthenia presents transition forms into hysterical insanity and some cases is to the traumatic neuroses. They are also apt to be very passionate. and are always very susceptible to alcohol. cases described above represent the usual disease Instead of predominance of the sad disposition. at others stubborn. grumbling. the most prominent feature may be an ill-humored. dull. The disease first makes its appearance about the twentieth year. or a misfortune. quarrelsome. sensitive.380 FORMS OF MENTAL DISEASE cially following a mental shock. and may even become aggressive. Sometimes patients present a marked self-control. difficult to handle. are easily excited. a fright. and perhaps also great The patients are easily offended. with irreg- ular remissions but within certain limits it runs a very uniform course. There shows similarities no sharp distinction . shy. associated with a few hypochondriacal com- plaints. play Even during the remissions patients always dissome evidence of mental peculiarities they are . especially irritabilit)'. or unfriendly. quiet. is At is first remissions are apt to occur. The picture. In their actions they are unstable sometimes . but later there a tendency for the symptoms to persist. The course of the disease .

which disappears with rest. the greater to congenital neurasthenia. 1896. the ordinary stimuli have been elaborated only in a morbid manIn congenital neurasthenia there is always present ner. 1886. Binswanger. apt to prove with choice of surroundings. 1895. may even improve under the influence of exertion. whether or not the individual is overworked. while prolonged idleness deleterious. which must be suited to them. in which. are of value in creating new energy BIBLIOGRAPHY Saury. . but family strife and increased responsibilities diminish the chance of recovery.CONSTITUTIONAL PSYCHOPATHIC STATES 381 between congenital neurasthenia and acquired neurasthenia. a morbid indisposition. On the other hand. which play the important role. Die Pathologie und Therapie der Neurasthenie. The greater the deficiency in the original constituis tion of the diseased patient. Nervositaet uud neurastkenische Zustaende. —A well-regulated straint tends to increase the trouble. They very often need employment. the exercise of strength. absence of reTreatment. Krafft-Ebing. while in acquired neurasthenia there appears a simple irritability upon overexertion. and so adjusted as to gradually increase the responsibility and Both massage and gymnastics for work and in estabHypnotic suggestion is often lishing self-dependence. can make the patients very comfortable. the similarity from youth. iStude clinique sur la folie hereditaire (les degeneres). In congenital neurasthenia the morbid vacilla- tions of the emotions. life. helpful in cases with insomnia and complaints of pain. which acts is as a diversion.

Sometimes the content of the compulsive idea is purely in this indifferent. In a second group of cases there ponder over certain definite things. even them to themselves. First of all there appear simple compulsive ideas which force themselves upon the patients against their will. Odors and melodies can similarly haunt the patients. but patients exhibit may be unusually throughout a pronounced and frequently a clear insight into the morbidity of the individual symptoms. or feel as if is they were being shamed. Such ideas are especially annoying when they are nasty physician was in this of death. The in- not only undisturbed. and at others in the form of a congenital neurasthenia. fre- A way tormented with the thoughts Sometimes the idea is accompanied by a mental picture. One man was constantly seeing the hands of ghosts of whom he had once read. Evidences of a psychopathic condition may have existed from infancy. feeling of mental illness. and good. 382 a compulsion to for example. It is only the quent repetition of the idea that causes annoyance. Some patients are compelled to con- template the sexual picturing to dwell organs of those about them. The way influence the freedom of the train of thought. Others when at stool have upon all sorts of disgusting scenes. sometimes appearing as hysterical symptoms. the . or create horror. or at least not irritating.COMPULSIVE INSANITY In tellect this psychopathic state compulsive ideas and com- pulsive fears is form the predominant symptom.

and glasses. S. think of it. mal individuals. "phobias. form." " Why is that house painted green and called This. 217. "Why does that chair " Why does it have four legs and stand so and not so ? " no more or less ? " not brown ? " etc. 1 Psy. names feel that of people whom they meet on the street others they must form a definite picture of the face." the anxious conditions. knives. lying awake nights tryand the tension cannot be relieved until it comes to them. patients have these fears in spite of the fact that they know no harm can come to them. or color of the hair of strangers. the the hotel table. I. universe created objects in How was the Sometimes these questions refer come from ? " " the surroundings. street. agoraphobia (fear The of public places). 2 has been The so-called . the . 626. " Who is God ? " to " Where ? did he " etc. Berger. 1 383 and particularly names hard to remember. Griesinger. by Griesinger. the Incidents of this sort occur even in nor- Some patients feel compelled to inquire . 1893. Archiv f. Psychiatrische Vorlesungen. S. the patients immediately strain every nerve it. Another prominent tendency is to dwell on figures (arithmomania). when the patients are bothered with such questions as. the number of designs in the carpet or wall paper. " Gruebelsucht. as. VI. to get If unable to recollect a name casually heard or seen. ibid. nyktophobia (fear of darkness). etc. . or of his room in or he counts compulsively the guests about the number of forks.COMPULSIVE INSANITY names of persons (onomatomania). ing to recall it all day long. Frequently the compulsive ideas take the form of questions which may be of a metaphysical nature. When subjected to belong here 1 Magnan. when one is compelled to busy himself with the number of his house. also mysophobia (fear of dirt).

faintness. this. long. them. Some are unable to walk down a broad street. Psy. going over bridges. ling. These patients find no pleasure in traveldo not enjoy going to church or the theatre. Among other morbid fears might be mentioned that of being alone in the dark. they are some even remaining railing. ready to fly at the first sign of danger. 130 . in which patients fear blushing. or in a place where they are alone. The pronounced superstitions exhibited by many are allied to these fears. which causes great discomfort for fear that they of may be thought guilty some misdeed. X. is they are so overcome that they is extreme. Ill. Westphal. nausea. riding on trains. and alsit ways near the door. 621 . When they attempt cannot proceed. and finally may even lose The best known of control of themselves and collapse. 48. Some patients have fear of impending illness or some chronic disease. Closely related to this the fear of height which prevents patients from standing near a on the brink of a precipice. Archiv f. When on the the condition street at all. s. weakness of the legs. . afraid to go out in bed. tremble. and going through tunnels. s. When any one enters the room or name is spoken they immediately blush. become pale. Ill. have a cold sweat. they suffer may these conditions is agoraphobia. 1 The ibid. It may even create so much annoyance that they are compelled to give also the fear of up business. There is wearing new clothing because of the new- and accompanying physical discomforts. Cordes. or of being in a theatre.384 FORMS OF MENTAL DISEASE from palpitation of the heart. countless bacs. Among the numerous phobias another is the fear of dirt ness contagion or infection (mysophobia). polyuria. 1 when the patients are in fear of public places. There their is also a condition called erythrophobia.

and from touching money. there are those cases where the patients are not in so are fearful disease The much are fear for themselves as they are for others. some important finally letter into the fire. patient has the fear of destroying some- thing of value. patients are constantly washing of themselves. they are afraid of handling brass or copper. or have poisoned a relative. many cases the fears are quite silly in spite of better judgment. Then quently. or destroying for this reason carefully and avoided touching any paper and even printed books. in the severer forms they influence the actions of the patients. especially. One lady was always in fear of throwing it. Perhaps it would have been better if they had not drunk that glass of water. books. down and write a letter in order to be sine that they are is understood. They notice in their food a shining bit which Occasionally a may possibly be a pin. or are always taking things up by nails or pieces of glass. or In taking food they have to wipe the dishes frepapers. but the letter barely off before they are in doubt as to whether they made themselves clear in it. fear constantly in They that they may not have made After leaving a friend they sit themselves understood. trying to avoid false interpretations. In the lighter forms these doubts exist only in one all field of activity . are avoided as a possible source of contagion.COMPULSIVE INSANITY teria 385 always present in the air are one of the chief sources complain- of annoyance. or they possibly have harmed themselves by taking that 2c . The patients are everywhere ing of the bad air and throwing up windows. have committed a theft. Books. These patients weigh every word before they express In themselves. they feel that they are guilty of crime. and inspect carefully every bit of food. of homicide.

of washing. but not the strength. They have an insight into their condition. They no longer offer to shake hands. dependent nature. but wear gloves and open windows with their elbows. not only their hands. undressing. because the glass might break and cut them. Some dressing. which often is in marked contrast to their courage in real danger. A common characteristic of almost all phobias are the . FORMS OF MENTAL DISEASE Had . sealed a letter that they have mailed. They begin the habit they injure themselves. They are usually of a weak. their bodies. to free themselves from it. day in and washing themselves and their patients spend the entire The consciousness of all these patients is entirely clear.386 piece of cake. the result of fear of misplacing something or of soiling themselves there develops the fear of contact. or have Consequently. In their be- havior and actions they frequently show nothing abnormal. " delire As du toucher " of the French. They know well enough that no real harm threatens them. because of the uncertainty as to whether they have closed a door. and control themselves perfectly before strangers. or tearing open letters if to see they have enclosed the right one. but that they are overwhelmed only by the " fear of the fear. nave been better It is actually or that fire would not have broken out. clothing. it would an accident would not have happened the little They are always turning back to see if they have locked the door. there arises an ever increasing painstaking in details of daily life. but also all may of their clothing. all they not gone out of doors. impossible for them to remain at rest. and a desire." Their emotional attitude shows anxiety. All the needles in the house give up sewing for fear that are thrown away and they The windows are no longer washed.

The course of the disease varies much. and then only Rapid improvement is often noticed. when such questions as the following keep arising " What would happen if you should undertake to do this or that if you should kill some one with that knife lying there. 387 As soon as one threatens to do that feared by the usual patient. first The symptoms often follow some shock. . until It is quite astonishing to see how the now hoping for relief of the disease. Treatment. or set that building on fire. patients. etc. Complete disappearance of the symptoms seldom occurs. The prognosis is unfavorable. and they must be impressed with the fact that they will overcome it more by abstraction and diversion than by exercise of will should be warded power. — In youth careful attention to the demands of physical development iarities is necessary. always be made clear to the patients. : : handle matches. off Threatening pecul- by careful training and all deleterious influences removed. he develops an anxious condition with excitement. for a short time. It appears usually during the period of development. which tend to weaken the The symptoms physical and mental powers of resistance. or shout aloud in church ? " For this reason they avoid the use of sharp instruments and never ing it. sud- denly turn about and oppose any real attempt at combat- There are other patients whose compulsive fears seem to take the form of impulses. of the disease can be combated by persistent and patient training with a view to strengthening and encouraging the patient to struggle step by step against the morbid The significance of their condition should compulsion.COMPULSIVE INSANITY crises. or to hinder him from carrying out his means of protection.

S. VIII. Aichiv f. 737. . Kaan. Der neurasthenische Angstaffect bei zwangsvorstellung und der primordiale Gruebelzwang. 1893.388 FORMS OF MENTAL DISEASE BIBLIOGRAPHY Westphal.. Psy.

for constantly whom the impulses are involving the environment and interfering with comfort and occupation.IMPULSIVE INSANITY Impulsive insanity is characterized by the development of morbid tendencies and impulses which may continuously predominate over volition or appear only in paroxysms. and at hearing the crackle. are performed because of an irresistible impulse. Another to set fire (pyromania). which is exhibited especially during puberty. In some cases the morbid impulses are all in one Of these the most important is the impulse direction. often Somemost by young females. A transition state from normal impulses to impulsive insanity may be seen in those individuals in whom such dis- impulses are quite trifling and indifferent. finally forcing him to sneak out at night in order to perform But the disease becomes of great imthe absurd act. man who portance to the patient. which appear without motive. thereby causing the actions to appear unpre- meditated. dates from early childhood. are quickly executed. purposeless. but appear suddenly. Maudsley tells of a and lead to very simple deeds. perhaps only under unusual circumstances. These acts. times the morbid pleasure of seeing things burn. common form of impulse of this kind 389 is seen in the . and often quite indistinct. appear and appear rapidly. The impulses do not arise as the result of a conscious plan. and even absurd. for weeks was annoyed by an impulse to overturn two stones which lay upon a wall.

and fetichism. of the disease appear only during cer- The symptoms tain periods of life. those women's shoes and many exhibitionists belong to this class. The morbid impulses sexual impulses which have been called sadism. In some cases there a desire for some one . Only occasionally is noticed. shy. Here there exists a close relationship to instances. who may be childish. The men who prod women. One should not confound the the criminal irrevocable relapsing of with the regular repetition of similar criminal acts in these patients. but in some severe cases there is a more or less high grade of mental weakness. and the patients snip hair. the irresistible tendency to play.390 FORMS OF MENTAL DISEASE tendency to skilful but foolish stealing (kleptomania). and a stable personality. and many similar digressions. at which time there resistance in a condition of lessened both the physical and mental fields. steal or linen. or seclusive. definite thing. articles are frequently almost or quite worthless for the is patients. this condition. and esThe stolen pecially during menstruation and pregnancy. and particularly during the period is of development. slash ladies' dresses. In some is cases there the formation of periodicity improvement with development. Sexual impulses may accompany Further seen expressions of degeneracy of normal impulses are in the silly fondness for animals. encountered almost exclusively among women. marked increase of sexual impulses. The mental endowment of these patients usually shows no marked defect. to destroy and kill are other There is a special group of young women who show a morbid impulse to beat little children entrusted to their care. masochism. The . which is accumulated in great quantities. In the mental field there is apt to exist some weakness.

These patients do not confine themselves to deeds close at hand . impulsive approaches very closely some forms of compulsive insanity. and on the The two important other with simple compulsive fears. tion of society. and morbid. unnatural. characteristics of impulsive insanity are that there is no clear and rational purpose for the deed. and they cannot remain quiet until it The act is immediately followed by a feeling is done. and especially when. and steals. but he does it from and for some definite purpose. tance that the patients do not become addicted to the There are some cases. idea of the of relief. Here there is apt to be associated with the morbid act a feeling of desire and eagerness for the performance. There is is not a trace of penitence. after the excitement of the deed. are evident defects in other fields of the psychical The treatment of impulsive insanity naturally lies in the education of the patient. for the protecuse of alcohol. perhaps to do some one injury. 391 kills. need to be confined in an institution. Here they can be educated to lead a useful life. but failure brings disappointment at the result. they often have an abhorrence of them and fear that they may yield to something which really does not exist. On the other hand. who. it is clear that we have on the one hand to do with real morbid impulses. and that there life. individual to the deed against his will. which must be adapted to individual cases and carefully conducted with proper regard It is of greatest imporfor the physical development. and the dominating impulse forces the selfish motives. except where there some moral defect. those opposing ideas appear which have been forced to the background by the overwhelming desire.IMPULSIVE INSANITY criminal sets fire. For this reason. . is Frequently he insanity has a feeling that the action inconsistent.

that the peculiar perversion of the sexual impulse is congenital. ladies' tailors also among theatrical Moll claims that women comedians are regularly homosexual. Sometimes passionate friendships exist among young dren it is chil- who are still ignorant of the sexual differences. lays some stress upon accidental factors. etc. in his own morbid experience. such as the intercourse of naked boys while bathing. exhibited by individuals of the same sex for each other. waiters. prevalent claims to have encountered two among men. the cases reported to date numbering but a few hundred. wrestling. with an indifference or even an abhorrence of the opposite sex. — The contrary sexual It is instincts are far more an uncommon condition. and Schrenk-Notzing. in certain hundred cases. refers to those sexual juropensities appearing in youth. although homosexual patients maintain that it is by no means rare. which happen to exert an influence upon the sexual feel- ings long before the age of sexual development.CONTRARY SEXUAL INSTINCTS This psychopathic mostly state. It a view of Krafft-Ebing. Etiology. on is The condition develops from a the other hand. It is employments. The condition has also been well described by Krafft-Ebing. Schrenk-Notzing. emphasized by the statements of the patients themselves. Moll. Ulrichs. 392 But only with the abnormal child that such accidental . such as among . state of degeneracy. which received its name from Westphal. more prevalent people. decorators.

Symptomatology. The patients. though in some cases such relationships are maintained social uals. usually to a — Sexual impulses - develop early. both in the waking and dream states. that the morbidity of the condition depends not from the onset. but sometimes the patient desires intercourse only with a normal individual. intercourse are unsuccessful. origi- nating in a hereditary state of degeneracy. Differences in rank A few patients of the better classes are attracted by mechanics. and kiss- exhibitions of jealousy. and occasionally to masturbation and other forms of sexual perversion. Those who do importance than in normal individ- . This frequently extends to embracing. The patients usually remain unmarried. In these friendships the physical and mental superiority of one individual over another may aid in arousing the Usually both individuals are homosexual. but rarely to pederasty. is of less for years. letter-writing. and especially by soldiers. then. sending and flowers. often occur. and to onanism. showing the fickleness of the patients. Close associations of the some individuals into same usually formed with which usually develop display of passionate friendship with extravagant gifts affection. ing. upon impulses which are perverted but upon a characteristic tendency. It seems most probable. sometimes leading first. sexual feelings. with disruption of these friendships. Frequent changes of the affection. or accomplished only with difficulty.CONTRARY SEXUAL INSTINCTS influences 393 upon the early sensual feelings can have any power in the later development of the sexual impulses. Attempts at natural sexual are sex. experience pleasurable sexual feelings only in con- nection with their own sex. marked degree. The natural heterosexual impulses may have developed being displaced later by stronger morbid tendencies.

394

FORMS OF MENTAL DISEASE

marry, either in the hope of overcoming their perverse tendencies or from the desire to have children, are usually
true to their marital duties, except in the matter of sexual
intercourse.
larly, in

Some

indulge occasionally, but more, regu-

homosexual intercourse.

Other symptoms indicative of a morbid constitutional
basis are usually present, especially the physical stigmata.

Judgment

is

usually unimpaired, as well as the ability to
is

comprehend, but there

an increased sense of fatigue, mental work, and a tendency to lack of perseverance with dream. Imagination is prominent and interferes with the
capacity for purely rational activity.

Some

are especially

endowed
artists
;

in

an

artistic

way, being good musicians and

but they also possess a keen sense of appreciation

Mental weakness may exist. Many have an insight into the morbidness of their impulses, and defend themselves on the ground that the impulses are the natural and involuntary product of their
of their abilities.

patients

constitution.

In the emotional

life

they present

irritability,

are sensitive,

moody, and impressionable, often timid, and
In actions they

given to passionate outbursts of feeling.
times sluggish.

appear effeminate, vain, pliable, unstable, and are some-

They

are often careless about their work,

easily distractible,

and untrustworthy.

The sexual im-

pulses are apt to gain control over them, causing neglect
of business.

Fetichism and other perversities
of

may

also be

present.

The condition
sionally

psychic

hermaphroditism
feelings

is

occa-

present,

when

sexual

are

exhibited

toward both sexes, though usually stronger toward one sex than the other. Where homosexuality is very pronounced, the individual may experience a change of personality, a man becoming feminine in manner, gait, and

CONTRARY SEXUAL INSTINCTS
countenance.

395

He becomes

affected in manner, vain, co-

quettish, takes great pains with his personal appearance,
desires to be in fashion,

wears flowers, and uses cosmetics. Some develop a fondness for women's employment, do needlework, arrange their rooms after the fashion of a

woman's boudoir, and they may even dress in women's clothes, padding the hips and breast, talk in a falsetto voice, and in every possible way simulate feminine traits.
Early evidences of such traits
in childhood.
istics

may make
;

their appearance

A

few patients present physical character-

indicative of the opposite sex

men

are beardless,

possess high-pitched, light voices, have soft white skin,

with a more marked pannicus adiposus and well-developed

mammae

;

while the homosexual females have a deep,

and show a tendency to grow beards. The former are called by Krafft-Ebing androgyny, and the latter gynandry. Hermaphroditism has never been encountered in homosexual individuals. The course of the disease, which usually reaches its full development between twenty-five to thirty-five years of
coarse voice
age,
is

always prolonged.

In the acquired homosexuality

there

is

often a long struggle before the patient becomes

a

confirmed pervert.

The homosexual tendencies may

appear periodically with or without accompanying states
of general excitement.

Diagnosis.

It is

not a
traits

difficult

matter to identify
of

homosexual
transposition

patients where there has been a marked
of

the

characteristic

the

sexes.

Yet normal

sexual instincts

may

exist in spite of such a

Usually the condition becomes known to the physician only through the communication of the It is necessary to distinguish between contrary patient.
transposition.

sexual instincts and mere practice of homosexual acts,

396 the
latter

FORMS OF MENTAL DISEASE
being
pure perversity,
return
to

as

practised

among

prisoners, etc.,

who

normal sexual relations

upon gaining freedom. The prognosis is more favorable than is usually thought. Very many cases improve and some even recover under
the influence of treatment.

Treatment.

— The

most successful method of

treat-

ment
is

is

through the use of hypnotic suggestion.
is

This

directed first against the increased sexual excitability

and masturbation, which
sex,

frequently present

;

next

it is

applied to the insensibility of the patient toward his

own

and

finally

in

creating an excitability toward the

opposite sex and a tendency to heterosexual intercourse.

The hypnotic
difficulty.

influence over the patient, dealing as
is

it

does

with a deeply rooted habit,

acquired slowly and with

Schrenk-Notzing lays great stress upon regular

natural intercourse, but excessive coitus

because

it

may have an
is

injurious effect

must be avoided, upon the self-

Treatment directed at the general nervous also of importance, and should include the establishment of a routine in the physical and mental life, with attention to the diet, exercise, and relaxation. One should remember that even though marked improveconfidence.

condition

ment
still

or recovery takes place, the original defective basis

remains.

BIBLIOGRAPHY
Westphal, Archiv f. Psy., II, 1. v. Krafft-Ebing, Psychopathia Sexualis, 1900. Moll, Die contraere Sexualempfindung, 1891. Schrenk-Notzing, Die Suggestionstherapie bei krankhaften Erschei-

nungen des Gerschlectssinnes, 1892.

DEFECTIVE MENTAL DEVELOPMENT
Under
this

heading are described those mental states

which are the result of an incomplete or early interrupted development of mental life. In distinction from the process of mental deterioration these states may be regarded as conditions of retarded mental development. These conditions, however, may be closely associated with each
other, as

when a

deterioration psychosis appears in indi-

viduals with defective development,

when
is

either the per-

version or the deterioration

may

be the more prominent.

A

defective hereditary

present.

endowment The pathological basis for

almost always

defective

mental

development is the incomplete development of the cerebral This is often due to some disease occurring during cortex. fetal or infantile life which has an injurious influence upon the developing nervous elements. Our knowledge
of the anatomical facts
is

as yet so incomplete that
basis, to

it is

impossible,

on a pathological

differentiate

be-

tween the different grades of ment. In a general way the lighter forms are designated imbecility ; and the severer, idiocy.

defective mental develop-

IMBECILITY
This form of defective mental development is characterized by a moderate degree of mental incapacity, which is
usually of equal prominence on all sides of the mental life ; it may, however, involve chiefly the moral field, when it
is

sometimes called moral

imbecility.
397

Clinically, imbeciles

398

FOKMS OF MENTAL DISEASE
be divided
into

may

two groups, the stupid and the

active,

according to the degree of mental activity.

The fundamental symptoms in the stupid form are stuThere is an inability to receive pidity and insensibility. many impressions, or to grasp and utilize the experiences consequently the knowledge of the outside world of life
;

confines itself to the immediate surroundings, while events

without their narrow mental

horizon

pass

unnoticed.

Probably the sensory presentations are retained, but there
is

an absence

of a unification of single experiences into

general ideas.

Individual and insignificant elements
of experience.

make

up the fund

There

is

no comprehensive

elaboration of experience, and general relations are appre-

hended without the establishment of any definite points Essential and fundamental relations and disof view. tinctions are not recognized. Thought is scanty, limited mostly to daily experiences, usually travels the same path,
and, according to the research of Buccola,
is

really retarded.

Judgment is defective and uncertain and often determined by chance ideas not the outcome of past experience.
Patients also
fail to

consider the possible consequences of

their actions, either in reference to themselves or others.
is accurate only for the most prominent events of Yet sometimes trifling incidents are firmly retained, while the more essential are forgotten. The narration of events as remembered by them is noticeably faulty because of numerous omissions and changes. The same narrations at different times show many contradictions, though some-

Memory
life.

times they are repeated word for word.
is

Consciousness

unclouded.

The

patients

recognize the surroundings

their

and comprehend questions. They have no insight into mental condition, but usually regard themselves as

perfectly sound.

IMBECILITY
It is quite in accord

399

with these mental characteristics

that in the actions and conversation of patients their
personality should always

own

come into prominence. The narrower one's experience, the more prominent is the role of the Ego, leading in the case of the imbecile to more or less marked selfishness. The central point about which
the whole
lif e

revolves

is

their

own

physical well-being,

eating and drinking and the possession of things desired,

— —

while

all else is indifferent.

Occasionally they

fail to

show

the natural affection for parents and relatives.
ficial

The

super-

sorrow at the

loss of

some

relative

is

quickly lost in

the

pomp

of the funeral procession

suit of

mourning.

The absence

of

and the joy over a new sympathy for those

are in want and unfortunate may explain the cruelty which they sometimes display toward animals and in their combats with others.

who

Lighter grades of this type of imbecility often fail of recognition because of the absence of sharp border lines

between them and the stupidity sometimes present in Imbecilic defects, however, become normal individuals. as the individual advances in apparent more more and
compelled to take up some responsibility in life. Yet these defects may not be recognized because of the patient's ability to utilize a certain amount of expeage and
is

and with some mechanical But just as soon as anything skill in a simple occupation. shock or a temptation, mental a occurs, extraordinary which demands discretion and decision of action, the mental and moral incapacity becomes evident. Unfortunately at this time their actions are judged from a legal
rience

and

to engage regularly

and not from a medical standpoint.
pline brings to the light

Rigid military

disci-

many

such cases, especially in
is

those

countries

where

military service

required.

It

;

400

FORMS OF MENTAL DISEASE

becomes most apparent in stubbornness, insubordination, Lack of judgment desertion, and attacks upon officers. in handling these cases sometimes results in suicidal
attempts.

Imbecility

is

usually recognized at an early date.

In

infancy
ing

it

may

be noticed that patients are tardy in learn-

how

to laugh, to imitate,

and to speak.

Later, at

school, they are backward in studies, are sluggish, indolent,

show poverty of thought and inability to comprehend, and soon become the sport of their playmates. They find difficulty in learning to read, write, and reckon, and the few facts in geography or grammar, committed to memory, are
soon forgotten, since they are not essential to their limited
experiences of
life.

A

fairly

good memory may conceal

their incapacity for a long time.

The
ing,

patients are very often refractory, hard to train,

and have a tendency to develop bad traits, such as stealannoying dumb animals, and indulging in sexual improprieties, which often necessitates their commitment to industrial schools. During youth and puberty their mental incapacity becomes still more evident, because of the marked contrast to the rapid mental development of their playmates. At this time their own development comes to a standstill or may even retrograde, presenting resemblances to the progressive deterioration of dementia
praecox.

In the active or energetic type of imbecility, there is a morbid activity of the attention and imagination, in contrast to the general sluggishness of the stupid form.

Pa-

by every new impression, and unable to direct their attention permanently to any one object hence their observations are hasty and superficial. They are always ready to pass judgment without deliberation.
tients are attracted

IMBECILITY
This susceptibility to

401

new and

accidental impressions ren-

ders their view of the outside world very incomplete

and

fragmentary.
tions

Such vague pictures lead
basis for incorrect

to faulty concep-

and form the

judgment.

As soon

as ideation leaves the purely sensory field, the logical train
of thought yields to the influence of the lively imagination,

while the sharp definition characteristic of general ideas
disappears.

Circumstances existing only in their imagi-

nation are of far more importance in their deliberations

than absolute

facts. Thought, therefore, becomes unsteady and shows many inconsistencies patients vacillate in their plans from day to day, draw inconsistent conclusions from the same premises, and thus their views of life and the outer world lack reality.
;

Their nighty conversation contains a frequent repetition
of certain

high sounding remarks and commonplaces, which
little

often have

bearing upon the sense.

They are very apt
most diverse

to lose the thread of conversation, refer to the
subjects,

but usually finish with some very striking remark.

Such a bombastic style very often conceals from the inexperienced the actual mental enfeeblement, and leads to their

being regarded as unusually bright individuals.
in accord with these

It is quite

mental peculiarities that patients not only embellish and distort their recollections with many In spite of fanciful ideas but also fabricate extensively.
evident contradictions in their statements, they reassert

them

tenaciously,

and refuse further

discussion.

Accusa-

tions of the patients against relatives

and fellow-patients

should, therefore, be accepted with the greatest caution.

These energetic patients possess a better memory than the apathetic, are able to acquire some new knowledge, and to
adapt themselves to

new environment

to a certain extent.

The

emotional attitude presents a mobility equal to that

2d

402

FORMS OF MENTAL DISEASE

Every encountered in the attention and the imagination. rapidly but accentuated by an accompanied impression is
vanishing tone of feeling, and the moods vacillate from one extreme to another, showing despondency and exuberance, despair

and enthusiasm, which appear upon

little

provocation.
to

Violent likes and dislikes change from day

day

;

the dearest blessed doctor of to-day becomes the

vilest scoundrel

to-morrow.

While extravagant
tendency
to

in their

emotional
tability

expressions,

with a

emotional
Irri-

outbursts, they are readily diverted and pacified.

and sensitiveness are always present to a greater

or less degree, especially
interfered with
;

when

patients believe themselves

often they are docile and good-natured.

An

exaggerated feeling of self-importance regularly accom-

panies this form, some patients even believing themselves

endowed and often boasting of their prospects, while at the same time showing a lack of insight into Any shortcomings on their part their diseased condition. are explained by the hostility of relatives or lack of
specially

support.

In conduct the patients are odd, freakish, sometimes
loquacious, forward, pretentious, and silly
;

sometimes

quiet,

and manner or
docile,

reticent.

They are apt

to dress in a peculiar

to be slovenly in appearance.

They work with

varying

In youth they are frequently considered bright, by the parents, but later become fickle, unable to employ themselves at all, leave home, wander aimlessly about, drink, and indulge in all sorts of excesses. Many
zeal.

especially

prostitutes belong to this class.

In many of these cases, where there seems to be only a light grade of imbecility, there may be some question whether we are not really
dealing with conditions of degeneracy, but the presence of

profound mental deficiency, in spite of a certain amount of

is Morally. however. the last of which in seven per basis . are The intellect as regards matters of practical . moderately developed able to accumulate utilize for their more or less knowledge which they own advantage. single transi- tory expansive or persecutory delusions. chorea. cent. rarely hallucinations. possess a good memory. Gudden desig- nated such patients as " high-grade imbeciles. should leave 403 no doubt. etc. As signs of physical . Moral feelings. the basis for the development of other psychoses as manic-depressive insanity. puerile expression. lack the ability to obtain general view points. which includes chiefly the realm of the It is characterized of those feelings selfishness. misshapen ears. and an inaccessibility From this they develop the most to moral influences. anomalies malformation of the palate. to perform any mental work of a high grade. very often only individual symptoms of other psychoses appear. They do." Imbecility may form . imbecility represents another form of congenital mental weakness. the tendency to tease and use roughly playmates. and especially those attacks so characteristic of the constitutional psychopathic states.IMBECILITY superficial activity. such as periods of excitement and depression. we frequently find stigmata as. affection for parents and It is impossible to . their lack of sympathy manifested from youth up in their cruelty toward animals. of cases appears on an imbecile besides this. lack of sense of honor. and of relatives. degeneration of the skull. and show no defects in the process of thought. and to form an adequate conception of life or the outer world. life is which inhibit the by the absence or weakness development of marked patients apprehend well. not of the manic-depressive type. pronounced selfishness. the psy- choses of involution and dementia praecox.

Usually it becomes necessary at some time during their life to confine them in almshouses or hospitals for the insane. great and variable emotional moods. — . and stubbecome They The egotism becomes more and more evident in born. 40-4 FORMS OF MENTAL DISEASE them because of the absence of love train and ambition. while the susceptibility to alcohol is especially prominent. who can is diverted from this profession. bragging. and failing later senile in in mechanical arts. their great conceit. tell falsehoods. The character of the onset.. and wilfulness. which is a constant factor. them to some psychosis especially manic- depressive insanity and dementia. active forms of imbecility. is often an extraordinary persistency of the criminal tenin dencies these individuals. in this. unsuccessful in their attempts to enter a profession engage in develop become employed simple labor. give way to sudden impulses and emotional outbursts. and tion. crafty. — The course or to of imbecility varies considerably some patients. their indolence and dissipaThey are incapable of resisting temptation. Very many professional criminals present the symptoms In these cases of moral imbecility to a marked degree. Others show irregular periods of excitement. It is not infrequent for life. there fective heredity. dating irritability. with aggressiveness. There are some cases of dementia proecox which are difficult to differentiate from the lighter. they become a burden to the family. there is no doubt but that a scanty and defective training and education under circumstances unfavorable to a healthy moral development are of equal importance with the deIndeed. deceitful. Diagnosis. their inordinate desire for enjoyment. cialties no way be The development of spein among these criminals another expression of a one-sidedness of conduct. Course.

with a view to developing any capacity that best accomplished in the hands of may exist. getting a smattering of everything but knowing nothing thoroughly who take hold of everything new with enthusiasm. the absence of hallucinations and pronounced delusions. of the disease is is not as all uniform and the mental weakness sides of the psychical life not as evident on while in imbecility but few patients present hysterical symptoms. among which should be classed those weak-minded individuals who are over-credulous and superficial in knowledge. are easily led astray and indulge in excesses. speak for imbecility. in dementia prgecox patients while imbeciles present no may show some improvement. the patients develop is dangerous tendencies. This is some competent tutor directed or in a private or state institution established for that purpose. There are a few cases of hysteria with a moderate degree of deterioration which might be confounded with imbecility. Furthermore. except as much as might be consistent with the present productiveness of the patient. . If. and of any evidence of earlier acquired knowledge. — The treatment of congenital imbecility con- sists principally in providing an appropriate education. spite of training. .IMBECILITY 405 from childhood. Treatment. There are all possible transition stages between imbecility and the normal state. and who are always in doubt as to their real motives for action. but in them the course . hospital care necessary. change. but should include manual training. The use in of alcohol should be strenuously avoided. The training should by no means be simply toward mental education.

— tant etiological factors. Idiocy may be regarded as the final stage of hereditary degeneration. of birth. the closure of the suture has nothing to do with the malformation 406 . recent investigation showing that the growth of the calvarium is determined by the proportional growth of the brain and not vice versa. Furthermore. and diphtheria also head injuries. prolonged asphyxia. typhoid fever. but rather as an accompaniment. and rachitis. while Plate 10 represents . An extreme grade of the former of these conditions is represented by Plate 9. — the condition of microcephaly. congenital syphilis. measles. in which anomaly macrocephaly is far more prominent than microcephaly. Severe illness or mental shock Injuries at the time especially compression factors. Wildermuth finds defective heredity in seventy per cent. scarlet fever. mostly in the form of alcoholism in the parents. Defective heredity is one of the most imporEtiology. Premature ossification of the cranial sutures is no longer regarded as a cause of idiocy. Malformation of the cranium occurs in at least one-half of the cases. but by narrow pelves or forceps are probably important cases) the In idiocy developing after birth (one-fourth to one-third of most important causes are infectious diseases. Possibly also intoxication of one or both parents at the time of copulation predisposes to idiocy. of cases. during pregnancy and hereditary tendency to tuberculosis (Piper) have been noted as causes.IDIOCY Idiocy is characterized by a more profound degree of mental incapacity than imbecility.

Macrocephaly.Plate 9. .

.

— Many The male sex predominates. cases present defective development of the central nervous system. The cells themselves are embryonic in structure. More than one-half of idiots are first-born. inequality of hemispheres. The the whole number of cells is reduced. and four to idiocy. so that the different layers cannot be clearly distinguished (a characteristic of lower animals). changes. of genuine disease processes are found gitis. in regu- with a marked diminution in the amount of gray matter between them. while they stand closer together. causing extenSimilar conditions sive destruction of the cortex (porencephaly) or a general atrophy. menin- hydrocephaly. Pathological Anatomy. cortex is barely half normal thickness. . conditions which represent In some cases evidences . encephalitis. This faulty cortex. development may vary in different parts of the See Figure 1. In under-development the nerve its cells do not develop beyond an embryonic stage (Hammarberg). absence of corpus callosum.IDIOCY of 407 the brain. either smallness or increased size of the entire encephalon or malformation of some of its parts . being size mostly of the same and globular in form. are twins. and tumor formation. five per cent. or even a reversion to structures characteristic of lower animals. also occlusion of vessels caused by traumatic hemorrhage Microscopically. the excited forms. of which the most important are thrombosis. and embolism . may be due to vascular endarteritis. Plate 4. lar rows. at the time of birth or later. halting of development. find either we may an insufficient devel- opment of the neurones or evidences of former disease processes. of cere- bellum. Narrowness of the base of the cranium accompanies more often the profoundly stupid forms of and smallness of the vertex. sparsity or anomalies of convolutions and microgyri.

patients are unable to comprehend external impressions. either as an accompaniment or as a result of a de- generative process in the cortex. pound themselves diately repeat the act. presenting also an increase In the few cases of hypertrophic sclerosis. even to pieces of clothing and rubbish. if Idiots are not excitable they show very any. and indeed barely possess self-consciousness. Teething is delayed. or become acquainted with the environment. fear or pleasure. to gather new experience. they do not try to protect themselves. the severe and the light — forms. and the whole physical develop- . The patients eat anything placed before them. but there are number and arrangement areas in which the cells have entirely disappeared as the result of a disease process. of glia. but immewould impulsively bite deeply into the flesh of her arm. The nature of the causes which produce such lesions in fetal and early life is still unknown. They may be due to intoxication or infection. inflicting If repeatedly to cry out with pain. the impulses arising from these feelings lead only to simple actions.. manifesting some pleasure in kicking or swaying movements. confined to The emotional the general life is mere vacillations of feelings. the same place. One girl Some even wounds. In the most extreme cases of the disease. little. unless prevented. Consequently. are unable to form clear ideas or judgments. while hunger or physical pain may be expressed in pricked in monotonous or shrill cries. The symptoms of the disease are best considered in two groups. the increase in the size of the brain is due to the great increase of glia. causing them severely. such as the taking of food. at the most. 408 FORMS OF MENTAL DISEASE In other cases there the usual may be normal development. with of cells. Symptomatology.

. Microcephaly.Plate 10.

.

and. idiots present a mixture of incomplete words or syllables similar to the They do not imitate. and without connection. and a limited number of ideas may be formed. Memory is very poor. patients These are so utterly helpless that without constant attention they would quickly perish. play. IDIOCY 409 ment vacuous. is poorly Unable to form sentences. but the patients themselves are quite unable to direct the atten- few clear sensory impressions may enter consciousness. A establish a basis for the formation of is concepts. it is possible to fix the attention momentarily by the aid of some striking object. attracted toward any special individual. and therefore intercourse with the environment. or early efforts of an infant. to sway the head or body back and forth rhythmiretarded. The countenance is usually stupid and The movements are clumsy and awkward patients do not walk until late. they live indifferently from day to day. Idiots never feel which gratify a momentary pleasure. and some never even learn to stand but are absolutely helpless. which are extremely simple. there is no ability to make a selection from different impressions in order to tion. Convulsive attacks are of frequent occurrence. and liberate only those impulses for action developed. they may show sudden outbursts of . ment or opposed. a psychic personality never developed. The lower sensory or selfish feelings dominate the emotional attitude. Without thought or care for the future. with a tendency to move aimlessly about. and are very susceptible to fatigue. In the light cases. never express When irritated by rough treatgratitude or show grief. cally for a long time. always incomplete. Some restlessness may develop. or to grunt. to clap the hands. Speech. indeed.. busy themselves.

thought is sluggish and very pronounced emotional indifference. with there tendencies. morbid impulses. Physical Symptoms. late. . periods suicidal of anxiety. physical development dwarfish. attempting to destroy something or to injure Sexual desires may either remain undeveloped or one. for numbers or words. depending upon the distractibility of the attention. In idiocy periods of may occur which present some similarity to attacks of manicdepressive insanity. incoThe emotions change rapidly. such as a good memory skill. limited. In the active (erethisch) patients. The genitals are undeveloped menstruation absent. laughing. show purposeless rimning about. Hair is often absent from the face and pubes. at another. the stupid or anergic. and occasionally may be simple childish expansive or persecutory ideas. may appear. In the lighter grades of idiocy. or irregular. 410 FORMS OF MENTAL DISEASE some rage. A capabilities. . and there is time patients are stubborn activity. — There is a stunting of the whole the stature is undersized or even Countenance is childish. idiots or some simple technical Many are fond dis- of music. two types may be tinguished. patients eating ravenously and feeding themfew show some one-sided selves with their hands. the attention wanders aimlessly. Teeth are late . developed. appear early and lead to reckless masturbation and Often the appetite for food is abnormally sexual assaults.. filling consciousness with a variegated. Compulsive sometimes ideas. and the excited or active. Between these two groups there are numerous excitement or depression transition stages. The anergic patients are torpid. At one herent jumble. crying and clapping the hands. and the excitement which occurs in the end stages of dementia proecox.

.

Plate 11. . Casts of symmetrical and asymmetrical palates. the latter of which were taken from idiots and imbeciles.

end syllables stuttering. the bones of the face. They do not manifest a feeling of hunger. as paralysis or hemiplegia. and especially. IDIOCY in developing 411 and often faulty in arrangement. which early is only in infancy and in very childhood. These are to be compared with the normal palates seen in the top row. and faulty articulation of some or most of the consonants of the eye muscles. especially in memory limbs learn may remain how to walk or talk. of cases the so-called stigmata of degeneration are present (Wildermuth). blunted. are In eighty per cent. and may be continually restless . especially hearing. ears. The condition they do not and are unable to understand The distinction between the lighter degrees of speech. are not attentive. mirror-writing found. aphasia. malformation of the eyes. . and the asymmetrical. Other frequent symptoms are in. nose. paresis. especially in boys. and in thirty per cent. convulsions. incoordination of the lower and difficulty of speech. mouth. do not smile or cry.) The special senses. the lower four rows in which represent misshapen palates. in a fetal . Patients who show some mental development. halting. girls. idiocy and imbecility is often arbitrary. viz. even when lying upon the breast or at the approach of the mother.. crease or loss of the reflexes extremities. (See palate is usually Plate 11. of the cases. difficult — The recognition of the disease. many give evidence of some cerebral disturbance. especially lesions among are the Evidences of focal cerebral mani- fested by hemiplegia. depends upon the insensibility of the children to external influences. and with elision of all idiots are the awkward and is often show associated move- ments. contractures. Diagnosis. epilepsy (Wilder- muth). choreic and athetoid movements.

412 FORMS OF MENTAL DISEASE are in general but not in apprehension and judgment. rapidly go to the bad.e. case of Idiots left to themselves or in a poor environ- ment. recognize articles and resist what they have once experienced as disagreeable and appear to understand speech. removal of sources of focal irritation and Epileptic attacks should be combated with bromids. Besides treatment of the physical condition. the question of how much they can develop is of great importance. or other suitable measures. is The condition of faulty nutrition. which frequently present. the prognosis is more favorable. with the hope of preventing profound deterioration. is The appearance of epilepsy in early childhood very unfavorable. Such patients This. sisters Harmless patients in the or or brothers may become to threatening aggressive and are attempt sexual assaults. — Temperance in relief of in parents should be en- couraged as important prophylactic measure. insomnia. however. atropin. because of their lessened powers of resistance to intercurrent diseases. While idiots can never reach the rank of normal men. susceptible training. the patients should receive training in institutions for the feeble- minded. — The prognosis is unfavorable. somewhat . Crani- ectomy in some is cases of microcephaly is an irrational pro- cedure and fast disappearing from practice. usually short. the prevention of masturbation. considered as imbeciles. and they give evidence of memory. little puberty. In general it can be said that if their attention can be held for some time. Treatment. i. improves with the strict cleanliness. idiots often lose what During knowledge they may have acquired. and some even present the hebephrenic Their life is or catatonic picture of dementia praecox. Prognosis.

and more experience than can be obtained in the ordinary home. 1893. J. followed by special instruction in the perception of objects. as their inability to get along in the world and to utilize knowledge stands in striking disproportion to knowledge taught them. Der Idiot und der Imbecille. f. As a limited care result of such training. their treatment and trainBouneville. Studien und Klinik und Pathologie der ing. Idiote. continue to need some and supervision throughout life. Zur Aetologie der Idiot. 1893. Hammarberg. 1898.IDIOCY requires 413 a greater sacrifice of kindliness and patience. 1891. Die psychischen Stoerungen des Kindesalters. They. to direct their attention and to speak. 243 Sollier. Piper. Voisin. .. 1894. however. Assistance. and in forming simple judgments. in distinguishing them. An effort should first be made to teach them to walk and use their hands. 1895. Mental Affections of Children. Ireland. S. BIBLIOGRAPHY Emminghaus. many patients yearly leave institutions well enough trained to be of use in a field. 1893. traitment et education des enfants idiots et degeneres. Mentally deficient children. Idiotie. Shuttleworth. also to employ their different senses.

.

209. 15. in paresis. Cerebral abscess. 279. treatment. chronic. cerebral. Alternating insanity. Apoplectic insanity. 99. 383. 13. treatment. etiology. 251. acute. 249. 65. 141. 129. Apperception. Attention. 246.INDEX Abscess. 24. 176. 101. 126. 14. 141. prognosis. Apperceptive illusions. disturbances of. Acquired neurasthenia. Acute confusional insanity. symptomatology. Aphasia. 142. 8. 182. 90. Androgyny. 128. symptomatology. 58. 88. 93. Cerea rlexibilitas. compulsive. 132. Brain tumors. 113. course. symptomatology. 131. etiology. Circular insanity. internal. paresis. 222. in senile dementia. 111. 250. 23.) external. 145. etiology. 111. 110. treatment. Agraphia. 107. 102. Amentia. 221. 128. prognosis. 145. Ascending 383. Alcoholic intoxication. 307. Circumstantiality. hallucinations. 126. 107. 87diagnosis. Catatonic writing. predicative. Alcoholism. insanity following. symptomatology. pathological anatomy. prognosis. 257. Alcoholic pseudoparesis. etiology. Alcoholic epilepsy. 94.) Acute decubitus. prognosis. Alcoholic paranoia. Cocain intoxication.) Chronic alcoholism. 94. Cold packs. course. 102. 219. Cocainism. Catatonic excitement. 27. 90. treatment. diagnosis. 50. 101. 23. 95. 141. Apoplectiform attacks. 7. Arterio-sclerotic insanity. course. 96. Cell shrinkage. Acts. diagnosis. 50. 132. symptomatology. Collapse delirium. Cocain delusional insanity. etiology. 307. Alcoholic delusional insanity. Cephalalgia. 223. {See train of Agarophobia. Anxious tension. 91. 143. 110. 126. {See Association of ideas. 129. diagnosis. Apprehension. 110. 222. 97. 131. 415 . course. 395. 179. thought. (See abscess. amentia. Anxious excitement. course. Catatonic stupor. diagnosis. 129. insanity following. pathological anatomy. Arithmomania.

16. etiology. symptomatology. Delire du toucher. catatonic form. — pathological anatomy. treatment. 343. 396. symptomatology. 234. paranoid forms. physical symptoms. INDEX — Delusions (continued) hypochondriacal. 382. 212. pathological anatomy. Delirium. 162. 183. 39. 242. of jealousy in alcoholism. prognosis. physical symptoms. Dementia. treatment. prognosis. 153.416 Collapse delirium (continued) etiology. 151. 49. 375. Delusions. physical symptoms. 242. Compulsive insanity. catatonic form . course. symptomatology. 200. 387. nihilistic. diagnosis. 381. etiology. 200. agitated form. 236. 25. 89. treatment. prognosis. 38. 246. 149. 39. expansive form. 236. 122. Defective mental development. 31. clouding of. etiology. 393. etiology. Delirium tremens. first group. 86. 61. Convulsions. 40. 40. of the will. 162. 16. 149. 203. of jealousy in cocainism. 143. 386. pathological anatomy. 164. pathological anatomy. 337. 203. 35. fantastic. pathological anatomy. treatment. etiology. depressive. hysterical. 169. 124. course. Compulsive ideas. Dipsomania. remissions in. epileptic. pathology. Desultoriness. diagnosis. treatment. 75. 152. 40. 361. symptomatology. catatonic form. paranoid forms. 124. 162. persistent. paranoid forms. 378. second group. expansive. 149. prognosis. conscious. 241. 227. Distractibility. 39. course. 343. Cretinism. 129. prognosis. 196. Compulsive fears. 44. 237. demented form. 116. 1 74. 245. of jealousy in presenile delusional insanity. 396. treatment. 217. 39. symptomatology. 115. Congenital neurasthenia. treatment. 342. 12. 173. 387. diagnosis. etiology. 397. of persecutions. anxious. 191. 259. symptomatology. 160. symptomatology. acute. 184. 117. Contrary sexual instincts. 149. 188. diagnosis. course. hebephrenic form. primary. 154. Constitutional psychopathic states. Dementia precox. 38. 378. . 115. 392. 225. Coma vigil. course. depressed form. Consciousness. 268. 392. changeable. of self-accusation. 397. Delire de negation. 86. 123. 207. catatonic form. galloping variety. systematized. Disorientation. 387. 41. Dementia paralytica. 89. 39. 85. 188. Crises in compulsive insanity. treatment. hebephrenic form.

406. 394. 417 Flight of ideas. 346. 52. Epileptiform attacks. Emotional tone. 162. 249. 412. treatment. 29. persistence of. 333. 330. Epileptic dreamy Humor. Folie raisonnante. prognosis. 218. Echopraxia. 353. Hyperprosexia. prognosis. 180. 274. Hallucinations. Hebephrenia. 406. 6. 75. 395. 180. 49. physical symptoms. diagnosis. symptomatology. etiology. General feelings. Epileptic stupor. Fabrications. diagnosis. 331. increase of. 48. 3. 64. Excitement. auditory. visual. 52. 384. Exhaustion psychoses. 365. etiology. etiology. Hysterical pathology. Emotional deterioration. 10. motor. 344. 251. of 4. (See fabrications. change of. senilic. 411. 5. persistent morbid. Echolalia. drunkard's. subcorticalis chronica progressiva. idiopathic. 332. 53. Ecstasy. of. 17. 291. 348. Hypochondriasis. incomplete development 46. memory. physical symptoms. course. Erotic paranoia. 394. Illusions. 339. symptomatology. 30.) 105. 7. insanity following. symptomatology. states. 366. 321. 341. 407. prognosis. Fever delirium. physical symptoms. Hunger. Embolism. Goal ideas. 331. course. Epilepsy. 331. 412. 364. susceptibility to. dreamy states. 250. disturbances of the feeling Hydrocephalus ex vacuo. 47. 106. Hysterical somnambulism. Epileptic somnambulism. Erythrophobia. 329. 122. pathological anatomy. of. Fatigue. 74. disturbances of. in dementia paralytica. 46. 3. 74. 85. 21. diagnosis. Emotional irritability. 408. 366. in delirium tre- mens. Ideas. insanity following. of. elementary. 53. 67. 273. Head injury. Etat crible. 25. 74. Gynandry. disturbances of the formation of. 363. 362. Drunkard's humor. Ideas and concepts. Emotions. 337. psychic. 11. 361. 43. 365. 98. etiology. 329. 291. Epileptic insanity. Encephalitis saturninia. 46. Feeling of well being. 57. 215.INDEX Double thought. 76. Hasheesh delirium. 410. 2b . prognosis. Fear. treatment. Gliosis. cerebral. 76. 356. Idiocy. 29. Hysterical insanity. disturbances General neuroses. pathology. 252. 52. diminution of. 363. treatment. Hypomania. disturbance of the feeling of. 26. Fetichism. 112. tarda. Hermaphroditism. delirious form. 287. symptomatology. 341. 21. 48.

254. 382. 146. 283. 389. 78. Infection psychoses. 114. 14. 282. epileptic. alternating. insanity following. course. 228. circular. treatment. 65. 282. Melancholia. prognosis. of. course. 138. 135. chronic. compulsive. 105. 134. 254. 78. 66. pathological anatomy. periodical. delirium of. Moral imbecility. Involution psychoses. 309. abstinence symptoms. intoxication. Megalomania. pathology. 400. Morphinism. 262. symptomatology. 84. 76. Insolation. rangement of. diagnosis. 41. 293. 391. treatment. Mania. 307. 405. 181. 255. 76. 329. 33. Impulsive insanity. 263. mixed 77. 305. 307. 404. lucid intervals of. 18. etiology. simple. 137. prognosis. disturbances Mental elaboration. 305. active form. 284. Morphin 82. 403. 107. Korssakow's disease. course. INDEX Mania (continued) delirious. disturbances of. 67. depressive states. diagnosis. 105. 78. myxcedematous. chronic. 282. 113. 282. Mannerisms. 397. Insight. 134. 389. Malaria. Intoxication psychoses. 114. disturbances of the accuracy of. 73. stupid form. pathological anatomy. 299. 404. diagnosis. 255. 291. 20. disturbances of the caKleptomania. manic-depressive. symptomatology. 252. 308. Lethargy. Judgment and reasoning. stuporous. pacity for. treatment. mitis. physical symptoms. 62. maniacal states. simple. 135. 284. 262. etiology. Maniacal states. Impressibility. symptomatology. 19. symptomatology. . Manic-depressive insanity. 83. Mental work. hysterical. 138. course. 43. Maniacal stupor. 282. crossing of. 306. Impulsive acts. prognosis. Intoxications. 77. disturbances of. absence of. morbid. 261. 310. 18. treatment. 14. periodical. 291. course. Memory. — course. 291. 312. 67. 82. 255. 264. treatment. etiology.418 Imbecility. diagnosis. treatment. 134. acute. Infection delirium. treatment. 296. disturbances of the temporal ar20. pathological anatomy. prognosis. diagnosis. 353. Insensibility. 282. impulsive. Impulses. states. acute. 307. Masochism. Insanity. 398.

58. disturbances of. Pseudo-hallucinations. 339. Religious paranoia. 383. symptomatology. Sexual instincts. 282. Pleasure. 139. 272. 218. Psychic epilepsy. Psychoses. 316. 19. 7. 105. treatment. 273.) prognosis. 177. in dementia paralytica. 290. of. 81. 326. Querulent insanity. 317. 82. 340. pathological anatomy. Rambling thought. Retentiveness of memory. treatment. 267. 384. diagnosis. 278. infection. 321. 24. 288. 326. 301. pathological anatomy. Pre-epileptic insanity. Reflex hallucinations. 242. 273. Post-epileptic insanity. Neurasthenia. of. 273. disturbances of. Retardation. Negativism. Paralysis of thought. 139. 276. Senile dementia. Remissions. treatment. physical symptoms. Paresis. 267. 67. Mutism. 280. Pyromania.INDEX Morphinism (continued) prognosis. Myxcedematous insanity. (See contrary sexual instincts. Santonin delirium. Reperception. symptomatology. 316. Practice. periodical. 326. disturbances of the feeling 64. treatment. 79. diagnosis. disturbances Senile confusion. Periodical melancholia. 24. Pain. symptomatology. 106. 73. Muscular tension. religious. course. 277.) ascending. etiology. 67. 280. My8ophobia. Perception. Sexual feelings. with delusions and hallucinations. 30. alcoholic. Periodical mania. Persistent ideas. ( See acquired neurasthenia and congenital neurasthenia. Opium smoking. Post-febrile infection psychoses. 146. treatment. course.) Pressure of activity. 324. 249. 135. 25. Onomatomania. erotic. 321. (See dementia paralytica. 51. phantasms. 267. 279. of thought. Nyktophobia. disturbance of the feeling of. diagnosis. symptomatology. 321. Organic dementia. 8. diagnosis. Senile delirium. 252. 79. 271. 44. 21. 6. treatment. 55. Relaxation. 43. morbid feelings of. 317. 389. Pre-senile delusional insanity. Pseudo-paresis. prognosis. 184. 325. in catatonia. 111. prognosis. course. 81. 383. 176. 55. 317. 178. 59. 4. alcoholic. Self-consciousness. diagnosis. 419 infection psychoses — Post-febrile tinued) — (con- symptomatology. etiology. . 132. 3. Sadism. etiology. 270. 280. 253. Nausea. 43. 63. Paranoia. 222. Paralytic attacks in dementia para- lytica. 339. 272. 282. Paramnesia.

Stuporous mania. disturbances of. 289. hypersuggestibility of. Volitional impulses. in idiocy. 220. 56. 77. 42. 23. disturbances of the rapidity of. hereditary. 148. treatment. delusions of. diagnosis. etiology. 176. 204. 337. heightened susceptibility of. of. 147. Will. 411. 338. diminished susceptibility of. 249. 372. 373. Status epilepticus. . Traumatic neuroses. 60 symptomatology. Volition and action. 376. 60. Spirit possession. physical symptoms. 56. Sound Train of thought. leptic insanity. weakness of. scanning. diminution of. 303. 375. 371. Stigmata. 63. 57. disturbances of. catatonic. Unconsciousness. 61. prognosis. 57. 43. in paresis. disturbances in the release increase of. 42. INDEX associations. epileptic. Stupor. etiology. physical. acceleration retardation course. treatment. Syphilis. 146. 13. 371. of. in dementia paralytica. 62. 221. symptomatology. Transitory periodical ill humor in epi- Speech. 306.420 Smallpox delirium. 376. 146. 146. manic-depressive. 341. 59. Thought. of. 194. Thyroigenous psychoses. Stereotypy.

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