PSYCHE 
 
 A Concise and Easily Comprehensible Treatise 
 
 on the Elements of Psychiatry 
 
 and Psychology 
 
 for Students of Medicine and Law 
 
 BY 
 
 DR. MAX TALMEY 
 
 ' • ' • } • » 
 
 NEW YORK. 1910 
 
 The Medico -Legal Publishing Company 
 
Copyrighted, 1910, 
 
 BY 
 
 F. E. & E. L. TALMEY, 
 
 NEW YORK. 
 
 aiOLOQt 
 LIBRARY 
 
PREFACE 
 
 No -branch of medical science surpasses psychiatry 
 in importance. For mental disease is increasing in fre- 
 quency; it renders its victims dangerous to the com- 
 munity; it cuts short the lives of some patients and 
 permanently disables many; and, lastly, owing to its 
 hereditary tendencies, it contributes largely to race de- 
 generation. Yet the study of psychiatry has been greatly 
 neglected, chiefly due to the preposterous views, based 
 upon superstition, which prevailed in former times. Until 
 recently instruction in psychiatry was seldom given in 
 medical schools. To-day lectures in diseases of the mind 
 are held in the best medical colleges, but no final examina- 
 tion in psychiatry is required from the matriculates. It 
 follows, therefore, quite naturally that they pay little 
 attention to the subject. As a consequence the average 
 general practitioner is barely acquainted with the rudi- 
 ments of psychiatry. 
 
 The family physician should be able to observe the 
 earliest and salient symptoms of a case of insanity, know 
 their import and immediate dangers, and be in a position 
 to give a fairly thorough history to the consulting alienist. 
 But psychiatrists will tell you that such a family physician 
 is rarely met with, and that they are considerably handi- 
 capped by this lack of information. This ignorance was 
 the writer's incentive in compiling the present treatise. 
 He has endeavored to present the complicated subject of 
 
 281508 
 
iv PREFACE 
 
 psychiatry in a manner sufficiently plain to be compre- 
 hended with ease by those who need enlightenment in 
 such matters, but find it too laborious to wade through 
 more extensive text books. The writer hopes that he has 
 elucidated the intricate subject simply and concisely, and 
 has brought it within the horizon of the general reader, 
 and this will be his vindication. He further hopes that 
 with the foundation obtained the general practitioner of 
 medicine will be able to observe properly and diagnose a 
 case of insanity, to determine the prognosis, and to treat 
 the patient until the time when he has to be given into 
 the care of the more experienced specialist. Likewise 
 the book will be of value to the legal profession which 
 frequently has to deal with cases complicated by psychi- 
 atrical problems. The perusal of this simple treatise will 
 impart to an attorney an adequate knowledge of mental 
 disease and thus enable him to handle many a medico- 
 legal subject advantageously. 
 
 The Author. 
 New York, July, 1910. 
 
CONTENTS 
 
 PAGE 
 
 Introductory Remark I 
 
 PART I. 
 
 Psychology or Physiology of the Mental Functions. 
 
 Chapter i. Irritability of the Brain 5 
 
 Chapter 2. Sensations and Sense Impressions.... 6 
 
 Chapter 3. Association and Memory 8 
 
 Chapter 4. Perception 11 
 
 Chapter 5. Feelings, Emotions, Moods 13 
 
 Chapter 6. Physiologic-anatomic Explanation of 
 
 Feelings, Emotions, Moods 14 
 
 Chapter 7. Influence of the Affective State on the 
 
 Psychical Processes 18 
 
 Chapter 8. Physiological Explanation of the In- 
 fluence of the Affective State on the 
 
 Ideational Process 19 
 
 Chapter 9. Activity of the Understanding 20 
 
 Chapter 10. Activity of the Will 22 
 
 Chapter 11. Natural Impulses, Instincts 26 
 
 Chapter 12. Consciousness 2.^ 
 
 PART II. 
 General Pathology of the Mental Functions. 
 
 Section I. 
 Pathology of Feeling or of the Affective Sphere. 
 
 Chapter 13. Morbid Depression 31 
 
 Chapter 14. Influence of Morbid Depression on the 
 
 Psychical Functions 33 
 
 Chapter 15. Morbid Exaltation 34 
 
 Chapter 16. Influence of Morbid Exaltation on the 
 
 Psychical Functions 35 
 
 Chapter 17. Barrenness of the Affective Sphere ; 
 
 Want of All Psychical Functions. ... 36 
 
 Chapter 18. Irritable Affective State 38 
 
 Chapter 19. Perverse Feelings 38 
 
 Section II. 
 Pathology of Ideation. 
 Chapter 20. Morbid Retardation and Acceleration 
 
 of the Ideational Process 41 
 
 Chapter 21. Hallucinations 42 
 
 Chapter 22. Auditory Hallucinations 46 
 
 Chapter 23. Visual Hallucinations 49 
 
 Chapter 24. Tactile, Olfactory, and Gustatory Hal- 
 lucinations 50 
 
vi CONTENTS 
 
 PAGE 
 
 Chapter 25. Sequelae and Symptoms of Hallucina- 
 tions 51 
 
 Chapter 26. Delusions 53 
 
 Chapter 2y. Classification, Diagnostic Value, and 
 
 Sequelae of. Delusions 55 
 
 Chapter 28. Differentiation of the Delusions 57 
 
 Chapter 29. Systematized Delusions 58 
 
 Chapter 30. Fixed Delusions 59 
 
 Chapter 31. Disturbance of Memory in General. ... 60 
 Chapter 32. Abnormally Increased Capacity of 
 
 Memory 61 
 
 Chapter 33. Diminished Capacity of Memory 64 
 
 Chapter 34. Some Peculiar Disturbances of Memory 67 
 
 Chapter 35. Compulsory Ideas 68 
 
 Chapter 36. Morbid Alteration of the Activity of 
 
 the Understanding 73 
 
 Section III. 
 Pathology of the Activity of the Will. 
 
 Chapter 37. Increase and Decrease of the Frequency 
 
 of Volitional Manifestations yy 
 
 Chapter 38. Tics, Stereoptypy 79 
 
 Chapter 39. Interference, Derailment of the Will. . 81 
 
 Chapter 40. Hypersuggestibility, Negativism 82 
 
 Chapter 41. Morbid Alteration of the Energy 83 
 
 Chapter 42. Compulsory Actions 86 
 
 Chapter 43. Morbid Impulses 88 
 
 Section IV. 
 Pathology of Consciousness. 
 
 Chapter 44. Disturbance of Sleep, Somnambulism, 
 
 Hypnotism 90 
 
 Chapter 45. Double Consciousness, States of Cloud- 
 ed Consciousness in Epilepsy and 
 Hysteria 92 
 
 Chapter 46. Disturbance of Consciousness in Gen- 
 eral Paresis and in Deliria 93 
 
 Chapter 47. Disturbance of Self-consciousness 94 
 
 Section V. 
 Somatic Disturbances in the Insane. 
 
 Chapter 48. Disturbance of Sleep and of the General 
 
 Nutrition, Sitophobia 95 
 
 Chapter 49. Motor Disturbances 97 
 
 Chapter 50. Disturbance of Sensibility 98 
 
CONTENTS vii 
 
 PAGE 
 
 Chapter 51. Disturbance of the Activity of the 
 
 Heart \ 99 
 
 PART III. 
 Etiology of Insanity. 
 
 Chapter 52. Classification of the Causes of Insanity. 103 
 
 Chapter 53. Influence of CiviHzation 104 
 
 Chapter 54. Influence of Religion 106 
 
 Chapter 55. Heredity 107 
 
 Chapter 56. Stigmata of Hereditary Predisposition 
 
 to Insanity no 
 
 Chapter 57. Psychical Influences 113 
 
 Chapter 58. Influence of the Infectious Diseases.. 115 
 
 Chapter 59. Influence of Poisons 116 
 
 Chapter 60. Influence of Trauma 118 
 
 PART IV. 
 Course (Prognosis) and Therapy of the Psychoses. 
 
 Section I. 
 Course (Prognosis) of the Psychosis. 
 
 Chapter 61. Onset of the Psychoses 123 
 
 Chapter 62. Duration of the Psychoses 125 
 
 Chapter 63. Termination of the Psychoses 128 
 
 Sect [OX IT. 
 Therapy oi- [\<.\m'i-y. 
 Chapter 64. Common Reluctance to Institutional 
 Treatment of the Insane. Responsi- 
 bility of the Family Physician 132 
 
 Chapter 65. Transporting Insane Patients to the 
 
 Asylum 134 
 
 Chapter 66. Insane Asylum 137 
 
 Chapter 67. Treatment of the Individual Symptoms 
 
 of Insanity. 141 
 
 Chapter 68. Hypnotism in the Treatment of In- 
 sanity 147 
 
 PART V. 
 Special Pathology of Insanity. 
 
 Chapter. 69. Classification of the Psychoses 151 
 
 Chapter 70. Psychoses and Age of Patient 153 
 
 Section I. 
 Mental Diseases Commencing After the Early Stages 
 
 OF THE General Development of the Organism. 
 Chapter 71. Melancholia 154 
 
Vlll 
 
 CONTENTS 
 
 Chapter ^2. Stupor 159 
 
 Chapter 73. Mania 162 
 
 Chapter 74. Hallucinatory Insanity 170 
 
 Chapter 75. Primary Insanity, Paranoia 176 
 
 Chapter 76. Secondary Insanity 181 
 
 Chapter yj. Delirium 185 
 
 Chapter y^. Secondary Feeble-mindedness, Second- 
 ary Dementia 189 
 
 Chapter 79. Primary Feeble-mindedness, Primary 
 
 Curable Dementia 192 
 
 Section II. 
 
 Mental Diseases Dating From Earliest Childhood, 
 Idiocy, Cretinism. 
 
 Chapter 80. Definition, Classifications, and Physical 
 
 Stigmata of Idiocy 195 
 
 Chapter 81. Inferior Idiots 197 
 
 Chapter 82. Superior Idiots, Imbeciles 199 
 
 Chapter 83. Moral Idiocy, Moral Insanity 204 
 
 Chapter 84. Querulous Insanity, Morbid Litigious- 
 
 ness 209 
 
 Chapter 85. Originary Insanity 211 
 
 Chapter 86. Contrary Sexual Feeling, Sexual Per- 
 versity 212 
 
 Chapter 87. Cretinism 214 
 
 Section III. 
 Diatheses of Insanity. 
 
 Chapter 88. Hereditary Predisposition to Insanity, 
 
 Hereditary Insanity 218 
 
 Chapter 89. Hysterical Insanity 219 
 
 Chapter 90. Phrenasthenia, Psychasthenia 222 
 
 Chapter 91. Dementia Praecox 224 
 
 Chapter 92. Recurrent Insanity, Manic-depressive 
 
 Insanity 233 
 
 Chapter 93. Epileptic Insanity 242 
 
 Chapter 94. Paretic Insanity 246 
 
 Chapter 95. Alcoholic Insanity 257 
 
 Chapter 96. Delirium Acutum 263 
 
 Chapter 97. Traumatic Insanity 265 
 
 Chapter 98. Insanity in Organic Brain Diseases. . . . 267 
 
 Chapter 99. Senile Insanity 269 
 
 Index 273 
 
INTRODUCTORY REMARK 
 
 The definition of psyche or mind as the capacity of 
 Hving organisms for certain manifestations, such as per- 
 ceiving, feeHng, remembering, thinking, wilHng, etc., is 
 not exhaustive, but sufficient for the purpose of convey- 
 ing to the student a clear conception of the elements of 
 psychology and psychiatry. Anything relating to the 
 psyche or mind is designated with the attribute psychical 
 or mental. The bodily organ which forms the basis of 
 the mind is the brain. All the processes of the body, 
 the vegetative as well as the psychical functions, depend 
 on the brain. The treatment of the vegetative functions 
 appertains to neurology and neuropathology. Psychiatry 
 deals with the morbid changes of the psychical functions 
 of the brain, while the normal psychical phenomena form 
 the subject of psychology. A clear knowledge of the 
 former cannot be obtained without a preceding study of 
 the latter. The following concise description of the ele- 
 ments of psychology will facilitate the proper under- 
 standing of the subsequent exposition of the elements 
 of psychiatry. 
 
PART I. . 
 
 PSYCHOLOGY OR PHYSIOLOGY 
 OF THE MENTAL FUNCTIONS 
 
Chapter I. 
 IRRITABILITY OF THE BRAIN. 
 
 The brain cortex possesses the quaHty of irritability, 
 i. e., the tendency and capabiHty of reacting to external 
 stimuli. The irritability may be lowered to a minimum, 
 and yet no morbid change may be present. As a rule 
 the irritablity varies. In the course of the day it first 
 increases, then it decreases and recedes sometimes to a 
 very low level, due to the exertions during the day. 
 Restitution to the normal takes place during sleep. 
 
 Far greater than by work is the influence exerted 
 on the cerebral irritability by the blood circulation. If 
 both carotid arteries are compressed (p. 67), the cerebral 
 metabolism becomes greatly diminished, although the 
 brain still receives blood through the vertebral arteries. 
 The result of this reduction of the blood supply is that 
 the individual becomes quickly unconscious, i. e., he is 
 unaware of what is going on around him ; after awaking 
 he has no knowledge of what has transpired. Such 
 diminution of the irritability can be produced only arti- 
 ficially, but does not occur under ordinary circumstances. 
 
 How does it occur that the irritability is periodic, 
 decreasing in the day to be restored during sleep? The 
 brain behaves like a muscle which becomes fatigued 
 through work. During work the metabolism is increased 
 and waste products are generated in great excesses. These 
 metabolic products, therefore, cannot be carried off not- 
 withstanding the enhanced circulation during work. The 
 accumulation of the products of fatigue lowers the irri- 
 
6 ' *'" • PSYCHE 
 
 tability of the brain. Hence in the course of the day 
 we become less and less susceptible to external stimuli. 
 During normal, healthy sleep the brain accomplishes very 
 little work, the generation of new products of metabolism 
 is greatly diminished, and those accumulated before can 
 be carried off. The processes of repair being in excess, 
 the irritability reappears. 
 
 Sleep is, therefore, not a special function, as was 
 formerly assumed, but merely a certain state of the 
 brain. This can also be proved from psychical pathology. 
 Many a patient, after having gone through a psychosis, 
 lacks the ability for certain mental functions, the psycho- 
 pathological process having destroyed the cerebral mech- 
 anisms by which these functions are exercised. Perma- 
 nent insomnia, however, is never met with in a patient 
 after the cessation of the acute psychopathic manifesta- 
 tions. Now, if sleep were a function of the brain, the 
 cerebral mechanism for exercising this function would, 
 in some cases of mental disease, be destroyed and perma- 
 nent sleeplessness result. 
 
 Chapter 11. 
 SENSATIONS AND SENSE IMPRESSIONS. 
 
 The paths by which the brain, although excluded 
 from the external world by the solid cranial capsule, is 
 accessible to external influences are the blood and lymph 
 circulation, the senses, and the muscles via the nerves. 
 
 Effects of the circulation on the brain are observed 
 after hypodermic injections and after medication through 
 the alimentary and respiratory tracts. When morphine 
 is administered subcutaneously, cerebral symptoms are 
 
PSYCHOLOGY 7 
 
 soon noticed; the morphine is conveyed by the blood to 
 the brain and exerts its influence on it. AlcohoHc drinks 
 cause hilarity; alcohol enters the blood and is carried to 
 the brain. A protracted stay in a room filled with car- 
 bondioxide gas produces a state of stupefaction. 
 
 The most perfect way by which external influences 
 reach the brain are the senses, sight, hearing, touch, taste, 
 and smell. The eye reacts to light, i. e., to vibrations of 
 the ether. These produce a change in the retina, on 
 which "a picture is formed. The change in the retina is 
 conducted to the brain through the optic nerve. When 
 we "see," this means merely that our brain cortex, i. e., 
 the cortex of the occipital lobe, has been altered in a cer- 
 tain manner by ether vibrations emanating from a lumin- 
 ous object. A certain number of vibrations of the air 
 per second change the organ of Corti. The change is 
 conveyed through the acoustic nerve to the cortex of the 
 temporal lobe. When this part of the brain undergoes 
 the consequent alteration, we say, we "hear" or we have 
 a sensation of hearing. The same is the case with the 
 senses of touch, taste, and smell, and the numerous sen- 
 sations effected through the skin, for instance, by heat, 
 cold, etc. The sensations leave in the brain certain perma- 
 nent changes called sense impressions or sensory images. 
 There are accordingly visual, acoustic, tactile, gustatory, 
 and olfactory sense impressions or sensory images. 
 
 Finally, the brain is influenced by the muscles. The 
 new-born child cannot grasp an object, it cannot make 
 voluntary muscular movements. The movements of its 
 muscles are at first purely automatic. But just as the 
 stimulation of a sense organ produces a sensation, so 
 also does any muscular movement give rise to a motor 
 sensation. Such sensations leave in the brain certain 
 
8 PSYCHE 
 
 permanent changes, called motor impressions or motor 
 images. Through the frequent reflex movements motor 
 impressions are stored up in the brain. Only after the 
 accumulation of sufficient motor images the child learns 
 to grasp objects voluntarily. 
 
 The nature of the cerebral elements in which the 
 impressions are stored up is not known. Because of 
 their number the medullated nerve fibres are more read- 
 ily adapted to receive the irritations of the brain during 
 a whole lifetime than the cells. W. His calls the cerebral 
 fibres which supposedly receive the stimulations of the 
 hrdiin ''sensation fibres" {''Empfindungsfasern"). F. H. 
 V. Grashey agrees with His. Others do not assume sen- 
 sory fibres, but only "sensation cells" {"Empfindungs- 
 zellen"). But no matter which of these elements receive 
 the stimuli, a sensation ensues when they are excited. A 
 permanent change remains in the sensory element. It is 
 called impression, and may be regarded as the result of 
 the work done by the process of stimulation. (Chapter 
 8, p. 19.) 
 
 Chapter HI. 
 ASSOCIATION AND MEMORY. 
 
 The various sensations are localized in definite areas 
 of the brain ; for instance, the cortex of the occipital lobe 
 serves for the visual sensations. These areas, however, 
 are neither isolated nor disconnected. 
 
 The sensory elements, fibres or cells, of any one 
 sense are connected with each other. The connecting 
 fibres are called association fibres (Fig. i, a). In this 
 way sensations may be associated. 
 
PSYCHOLOGY 9 
 
 By another set of association fibres the sensory ele- 
 ments of one sense communicate with those of the other 
 senses (Fig. 2, aj. A visual sensation may thus be 
 effected through auditory stimuli. When we hear the 
 name of an object known to us, we have its image be- 
 fore us. 
 
 a 
 
 on 
 
 on 
 
 on 
 
 Fig. I. 
 
 The sensory elements, s, of a sense are connected by asso- 
 ciation fibres, a. Visual sensations received from the retina, 
 R, by way of the optic nerve, on, may be associated by means 
 of the association fibres, a. 
 
 A sensation not obtained directly from the peri- 
 phery, i. e., the senses, the muscles, or some other organ, 
 but by way of association fibres in the brain, is called a 
 memory image or an idea. Memory depends on asso- 
 ciation, as a simple example will explain. A dog seeing a 
 whip for the first time, pays no attention to it. If a blow 
 be dealt the dog with the whip, he receives a sensation 
 
lO 
 
 PSYCHE 
 
 of pain which is associated with the image of the whip, 
 and he runs away. Thereafter when the dog merely sees 
 the whip, he runs away just as he did when he first 
 received the blow. 
 
 Three factors are requisite for the accomplishment 
 
 on 
 
 V 
 
 on 
 
 on 
 
 an 
 
 \ 
 
 an 
 
 an 
 
 Fig. 2. 
 
 When the auditory organ, E, is stimulated, a visual sensa- 
 tion may be effected. The irritation travels from the ear, E, 
 through the acoustic nerve, an, to the auditory center, as, 
 thence through association fibres, ai, to the visual center, vs. 
 
 of an idea. Firstly, sensations must have taken place; 
 secondly, the sensations must be associated with one an- 
 other; thirdly, impressions of the sensations must have 
 been retained in the brain. Only then ideas can arise. 
 Bearing in mind the foregoing explanation of sen- 
 
PSYCHOLOGY ii 
 
 sations, impressions, association, and ideas — memory im- 
 ages — we may define memory in the following way. 
 Memory is the capability of producing, or bringing into 
 consciousness, ideas by zvay of association. Patholog- 
 ically ideas may be awakened in another way, namely 
 by hallucinations — which will be explained later (p. 44). 
 Such ideas are called hallucinatory ideas. They are not 
 brought about by way of association. Hence they do 
 not belong to the true province of memory. 
 
 Chapter IV. 
 PERCEPTION. 
 
 When the irritation brought about at the periphery 
 by an external stimulus arrives in the brain cortex and 
 produces a change in a . cerebral element, a sensation 
 takes place. Normally the individual, somehow or other, 
 becomes aware of the change, and we say, he "sees," he 
 "hears," etc. But it is conceivable that he may fail to 
 become aware of the change. This is physiologically 
 the case with the sensations of the earliest days of life, 
 and occurs only pathologically, as a rule, in the adult. 
 A person is mentally blind — ''seelenblind" — or psychi- 
 cally deaf — "seelentaub" — if he does not become aware 
 of the result of visual or auditory stimulation. Hence 
 we may distinguish a sensation which one is aware of, 
 and a sensation which one is not aware of. The latter 
 is a pure sensation, the former a pure perception. Both 
 are seldom realized in adult life. 
 
 In contradistinction to pure perception ordinary per- 
 ception of an object is a complicated process in which 
 association and reproduction — memory — are instru- 
 
12 PSYCHE 
 
 mental. The different points of the object furnish sep- 
 arate images. These are stored up in different cerebral 
 elements which are connected by association fibres. 
 When one partial image is presented to a sense, all the 
 other partial images are called forth — reproduction — by- 
 way of association, and the individual perceives the com- 
 posite image of the whole object. In all likelihood a 
 composite image is not deposited in one cerebral element. 
 When the child learns to see an object, it does not receive 
 its whole image at once, but by separate perceptions it 
 learns to compose the image of the object. The single 
 perceptions are stored up in different cerebral elements 
 as sense impressions which unite to form the complex 
 image of the object whenever a partial image is awak- 
 ened. 
 
 Three modes of perceiving may be distinguished. 
 I ) Simple perception consists chiefly of actual, momen- 
 tary sensations. 2) Intuition contains actual sensations 
 and memory images. 3) Phantasy is composed mainly 
 of memory images. A fourth mode of perceiving will 
 be treated later (Chapter 21, p. 42). 
 
 Most of the perceptions of the adult are intuitions. 
 A very young child receives only simple perceptions. As 
 experience grows, actual sensations are combined with 
 memory images. When a person enters his unilluminated 
 room at night, he is fairly well aware of everything 
 around him. The few actual sensations, which he receives 
 even in darkness, are supplied by supervening memory 
 images, and both impart to him a correct apprehension 
 of his surroundings. The pupil who has just learned to 
 read, needs a comparatively long time to grasp a long 
 word, while one who is already experienced in reading 
 sees the whole word at once, immediately after noticing 
 
PSYCHOLOGY 13 
 
 the first syllable, memory images furnishing useful aid 
 at the moment of the actual visual sensation which the 
 first syllable produces. 
 
 During the process of phantasy we abandon our- 
 selves entirely to our thoughts after having withdrawn 
 our senses from external influences. The memory im- 
 ages are combined, one image awakens another, often 
 against our will. This play, this coming and going of 
 the memory images, is called the ideational process, the 
 course of ideas, or the train of ideas. 
 
 Chapter V. 
 FEELINGS, EMOTIONS, MOODS. 
 
 Simultaneously with every sensation arises a certain 
 feeling. When a flash of light strikes the eye, the visual 
 sensation obtained is agreeable or disagreeable; a certain 
 sound has an exciting or soothing effect. The feelings 
 accompanying the sensations are called sense feelings or 
 affective tones of the sensations. They are best observed 
 in children. The sight of some object, the hearing of 
 some sound, produces in the child an agreeable or dis- 
 agreeable feeling, and the child manifests its pleasure or 
 displeasure in some obvious manner. 
 
 Not only the sensations, but also all other psychical 
 processes are accompanied by feelings. Every idea, 
 every volitional act, every operation of the understanding, 
 gives rise to certain feelings which may be called the 
 affective tones of these psychical processes. 
 
 A feeling is not a lasting psychical state, but a 
 transitory, comparatively slow process, and its effect on 
 the other psychical processes does not exceed medium 
 
14 PSYCHE 
 
 intensity. When however a continuous series of feelings 
 is distinct from preceding and following psychical proc- 
 esses, thus representing a separate entity, and at the same 
 time produces effects of greater intensity than a single 
 feeling does, such a sum of feelings is called an emotion. 
 (Wilhelm Wundt.) 
 
 Several simple feelings, arising simultaneously or 
 shortly one after the other, produce a composite feeling 
 of the first order. Composite feelings of a higher order 
 result from composite feelings of the first order. The 
 composite feelings differ from the emotions chiefly by 
 the greater effects which the latter exert on the other 
 psychical processes. 
 
 Composite feelings often pass into protracted states. 
 Such states are called moods or affective states. The 
 moods form the transition between feelings and emo- 
 tions. 
 
 There is an infinite variety of feelings and emo- 
 tions. The most conspicuous emotions are those of an 
 agreeable or disagreeable nature, such as joy, pleasure, 
 hope, surprise, sorrow, displeasure, disappointment, an- 
 xiety, fear, fright, anger, rage, etc. 
 
 The child manifests few affective tones. In the 
 adult, however, the scale of affective tones and emotions, 
 from the highest delight to the greatest fright, is almost 
 infinite. 
 
 Chapter VI. 
 
 PHYSIOLOGIC=ANATOMIC EXPLANATION OF 
 FEELINGS, EMOTIONS, MOODS. 
 
 The arising of affective tones may be explained by the follow- 
 ing hypothesis. The sensory centers are connected with a certain 
 
Fig. 3. 
 
 When the eye, R, or the ear, E, is stimulated, the irritation travels 
 through the optic nerve, on, or the acoustic nerve, an, to the visual 
 center, vs, or to the acoustic center, as, and a visual, or auditory 
 sensation takes place. The irritation travels further through asso- 
 ciation fibres, a-j, to the vasomotor center, vc, thence through vaso- 
 motor nerves, vn, to the cerebral blood vessels, cbl, the affection of 
 which changes the nutritive state of the brain, thus producing an 
 affectiv? tone. 
 
i6 PSYCHE 
 
 other center by means of association fibres (Fig. 3, ao). The stimu- 
 lation of this center arouses an affective tone just as the stimulation 
 of a sensory center gives rise to a sensation. When a stimulus 
 reaches an organ (Fig. 3, R. K), the irritation travels through an 
 afferent nerve (on, an), to the sensory center (vs, as), thence 
 through an association fibre (as) to the center of the affective tones 
 (vc). The irritation of the former results in a sensation, and of 
 the latter, in an affective tone. It thus follows that every sensation 
 will be accompanied by an affective tone. 
 
 The center of the affective tones is identical with the vaso- 
 motor center. When this center is irritated, the blood vessels 
 contract, the resistance in the circulation is increased, less blood 
 flows through the brain, and its state of nutrition is altered. The 
 stimulation of any center affects also that of the circulation by way 
 of association fibres (Fig. 3, ^2) and produces a sudden change in 
 the nutritive state of the brain. This change gives rise to a certain 
 feeling, an affective tone. 
 
 A simple experiment shows that the vasomotor center partici- 
 pates in the production of feelings and their combinations, moods 
 and emotions. When a rabbit is frightened, its ear becomes pale. 
 
 The condition of the brain depends upon its nutri- 
 tion, so that it varies when the nutrition is inadequate, 
 sufficient, or excellent. Insufficient nutrition produces a 
 state of anxiety, and in fright the brain's nutrition is 
 lowered to a minimum. Pleasurable feelings correspond 
 to a good nutritive state of the brain. 
 
 The brain being enveloped by the unyielding solid cranial 
 capsule, some mechanism must exist for its adaptation to sudden 
 changes in circulation. The space occupied by the receding blood 
 must be filled out by some other material. The hypothesis has been 
 advanced that liquor cerebro-spinalis vicariously replaces the blood. 
 When more blood flows to the brain, the space for it is supposedly 
 created by cerebro-spinal fluid receding into the vertebral canal. This 
 is physically not impossible, but would not suffice to provide enough 
 room for the inflowing arterial blood. Besides, the walls of the 
 vertebral canal also offer great resistance to the afflux of the cere- 
 bro-spinal fluid. Another regulation, therefore, must exist to render 
 the instantaneous change of the cerebral blood quantity possible. 
 This regulation is furnished by the venous system, i. e., the venous 
 sinuses and the veins emptying into them. The pressure in the 
 
PSYCHOLOGY 17 
 
 cerebral veins is slight. With each pulse beat which drives more 
 arterial blood into the brain, venous blood is simultaneously pushed 
 out of the veins into the sinuses and thence into the jugular veins. 
 In this way room is created for the arterial blood. Conversely 
 venous blood occupies the room when the affix of arterial blood is 
 diminished. It is even conceivable that with sufficient reduction 
 of the pressure in the arteries a reflux into the brain of venous 
 blood could take place. 
 
 The arterial blood supply is of vital importance to the brain 
 as shown by the experiment consisting in the compression of the 
 carotid arteries (p. 5). Death through hanging is caused by anaemia 
 of the brain, and follows suddenly or at least very quickly. Any 
 reduction of the blood supply lowers the faculties of the brain. 
 
 An affective tone arises through a sudden change 
 in the nutrition of the brain, the vasomotor center being 
 secondarily affected at any psychical process. An affec- 
 tive state or mood thus depends on the nutritive state of 
 the brain. When the brain is in a state of good nutri- 
 tion, a feeling of well-being, pleasure, joy, is present. 
 When the brain's nutrition is impaired, a cerebral dys- 
 pnoea, so to say, ensues, causing displeasure, pain, depres- 
 sion, anxiety, fear, etc. 
 
 Feelings, moods, and emotions admit, therefore, of a 
 physiologic-anatomic explanation. Anatomically they have 
 their basis in the vasomotor center and in the association 
 fibres by which it is connected with the other cerebral 
 centers. Physiologically the feelings and their combina- 
 tions are founded upon the transmission of every stimu- 
 lation from the senses and other organs to the vasomotor 
 center through the tracts described, and upon the influ- 
 ence which this center then exerts on the circulatory 
 system. 
 
 Different affective states are equivalent to different 
 states of cerebral nutrition. In the sane individual the 
 affective state undergoes a change by the arising of a 
 
i8 PSYCHE 
 
 new affective tone. He falls into a state of anxiety by 
 experiencing a sensation through which the nutrition of 
 the brain is impaired. In the individual of unsound mind, 
 however, the feelings and their combinations vary also 
 in another manner. 
 
 To explain the great variety of affective states, we 
 must assume that the nutritive states of the brain are 
 very manifold. 
 
 Two affective tones, occurring simultaneously or 
 shortly one after the other, may neutralize one another. 
 One misses a valuable thing. He looks for it everywhere 
 in vain and begins to worry. But the worry disappears 
 at once when further searching brings forth the lost 
 valuable. We laugh at a joke, but when we are in a state 
 of depression, the inclination to laugh is suppressed. 
 
 Chapter VH. 
 
 INFLUENCE OF THE AFFECTIVE STATE ON THE 
 PSYCHICAL PROCESSES. 
 
 The affective state exerts a great influence on the 
 psychical processes. In a cheerful mood our judgment 
 is entirely different from that formed in a mood of de- 
 pression. A merchant about to go into bankruptcy meets 
 a friend. The latter passes by without greeting him. 
 The merchant at once thinks that his friend despises 
 him. It does not occur to him that his friend may not 
 have seen him. If, however, the same merchant were 
 in a joyous frame of mind, and a friend passing on the 
 street paid no attention to him, he would say to himself, 
 my friend is so distracted, so absorbed in his own 
 thoughts that he does not even notice his best friends 
 who cross his way. In a cheerful mental state we have 
 
PSYCHOLOGY 19 
 
 the inclination to see everything in a favorable light; 
 everything appears gloomy to us when we are depressed. 
 
 A person suddenly frightened may for the moment 
 be unable to speak. Speech becomes often inhibited by 
 sudden depression. Memory and the ideational process 
 are impeded by the disturbed state of cerebral nutrition. 
 On the other hand, the stream of our thoughts flows 
 easily when we are in an exalted frame of mind. 
 
 To no less a degree than the ideation, the volitional 
 activity may be influenced by changes in the cerebral 
 nutrition or in the affective state. 
 
 Chapter VIII. 
 
 PHYSIOLOGICAL EXPLANATION OF THE IN- 
 
 FLUENCE OF THE AFFECTIVE STATE ON 
 
 THE IDEATIONAL PROCESS. 
 
 The following hypothesis will explain the inter- 
 relation between mood and ideational process. The 
 transmission of impulses through the nervous elements 
 is facilitated or impeded according to the tension and 
 resistance prevailing in them. The higher the tension, 
 the more easily the resistance is overcome. The reduc- 
 tion of the cerebral nutrition in a state of depression 
 (Ch. 6, pp. 14-15) causes a lowering of the tension. The 
 resistance is, therefore, surmounted only with great diffi- 
 culty. The sense impressions, i. e., the permanent changes 
 in the sensory elements (pp. 6-8) brought about by the 
 processes of stimulation, may be assumed to be changes 
 of resistance in these elements. Violent, i. e., disagree- 
 able, stimulations cause a great change and considerable 
 lowering of resistance. Mild, i. e., agreeable, stimuli, on 
 the other hand, produce little change and slight diminu- 
 
20 PSYCHE 
 
 tion of resistance. Hence the resistance remaining in 
 cerebral elements which have undergone a disagreeable 
 excitement is small, but in those having experienced 
 an agreeable stimulation is still great. The ideational 
 process depends upon stimulation of cerebral elements 
 by way of association (pp. 8-11, 13), and not directly 
 by actual sensations. Such stimulation, however, is weak 
 and suffices to affect only elements with slight resistance, 
 i. e., those which have been disagreeably influenced at a 
 former occasion. But it cannot excite elements with 
 great resistance, or those to which pleasurable impres- 
 sions have once been imparted. It follows that in a state 
 of depression or impaired cerebral nutrition with dimin- 
 ished nervous tension the memory images will be of an 
 unpleasant character. For the weak stimulation by way 
 of association can be effective only in cerebral elements 
 of little resistance, which contain impressions of un- 
 pleasant experiences. When the affective state becomes 
 exalted, the nutrition is improved and the tension is 
 raised. Stimulation by way of association is then suffi- 
 cient to affect elements with great resistance, which harbor 
 pleasant impressions. The enhancement of the nervous 
 tension helps to surmount great resistances. The memory 
 images are, therefore, of a cheerful nature, for they arise 
 in elements in which impressions of pleasant sensations 
 are stored up. 
 
 Chapter IX. 
 
 ACTIVITY OF THE UNDERSTANDING. 
 
 The ability of the brain to perceive an object is not 
 always the same. At some moments it is better fitted 
 for certain perceptions than at others. The condition 
 
PSYCHOLOGY 21 
 
 of the brain in which an object is perceived in the most 
 favorable manner, and which is associated with a pecu- 
 Har affective tone, is called attention. Perception aug- 
 mented by the advantageous influence of attention is 
 called apperception. 
 
 Apperception forms that basis of the activities of 
 imagination and understanding. The materials for these 
 activities are sensations, simple ideas, and collective ideas. 
 In both activities sensations and memory images are com- 
 bined in various ways, and thus higher, more complicated 
 perceptions are acquired. Collective ideas are dissolved 
 into their component elements or into simpler psychical 
 products. The activity of the understanding differs from 
 the activity of the imagination in that the former searches 
 and establishes comparisons and relations between the 
 psychical elements and products. Comparisons and re- 
 lations play an important part in the activity of the un- 
 derstanding, but are neglected in the activity of the 
 imagination. 
 
 The process of associating ideas in a regular way 
 with a certain end in view is called reasoning. The result 
 or conclusion hereby arrived at is a judgment. 
 
 That form of the activity of the understanding 
 which constructs, by combination, complicated psychical 
 products out of sensations and memory images is called 
 synthesis or induction. Dissolving psychical compounds 
 into their components is called analysis or deduction. 
 
 Reason is the capability of forming abstract concep- 
 tions, of operating with them and conforming one's ac- 
 tions accordingly. The difference between reason and 
 understanding, considered in a medical aspect, is only 
 quantitative. Kant probably started from a medical point 
 of view when in his definition of reason he said: *'A11 
 
22 PSYCHE 
 
 our knowledge commences with our senses, proceeds 
 thence to understanding, and ends in reason." 
 
 Chapter X. 
 ACTIVITY OF THE WILL. 
 
 When a stimukis is appHed directly to a muscle, the 
 latter contracts and a movement ensues. Such a move- 
 ment is a direct movement. If however a muscle con- 
 tracts, when some other organ, for instance the skin, is 
 irritated, such muscular contraction is called a reflex 
 movement. 
 
 The process of a reflex movement is best illustrated by a 
 simple diagram. If a portion of the skin (Fig. 4, ps) be irritated, 
 the impulse is conveyed through the sensory nerve (sn) to the 
 posterior horn of the spinal cord (ph). Thence it travels through 
 an association fibre, which forms a part of the reflex arc (ra), to 
 the anterior horn (ah) and then through the motor nerve (mn) 
 to the muscle (M) and causes the same to contract with a con- 
 sequent movement of the part. This is a pure reflex movement. 
 
 Reflex movements are independent of the will, tak- 
 ing place even when the brain has been severed from the 
 body. When the skin of a frog just decapitated is 
 pricked, the muscles of the irritated part contract. The 
 movements of the new-born child are also reflex move- 
 ments. The child sucks reflexly, moved to this action by 
 some remote irritation. The movements of the child's 
 extremities are reflex movements. 
 
 When an end-organ is stimulated, the impulse, after its 
 entrance into the spinal cord, takes also another course besides the 
 one described in the foregoing illustration. From the posterior 
 horn (Fig. 5, ph) it travels through the sensory tracts (st) to the 
 center of sensibility in the brain (sc) and leaves in the cerebral 
 
PSYCHOLOGY 
 
 23 
 
 cortex a permanent change, a 
 sense impression (Ch. 2, p. 7). 
 Likewise when a muscle con- 
 tracts, an impulse is trans- 
 mitted from the muscle (M) 
 through an afferent fibre of the 
 motor nerve (mni) to the 
 anterior horn (ah), thence 
 through the motor tract (mti) 
 to the motor center in the 
 brain, and leaves in the cortex 
 a permanent alteration, a motor 
 impression or motor image (p. 
 8). Frequent stimulation ren- 
 ders conduction along the 
 motor paths more easy by re- 
 ducing their resistances, and. 
 establishes motor images. These 
 two conditions given, a slight 
 irritation, e. g., a visual per- 
 ception is sufficient to effect a 
 movement. The visual impulse 
 is transmitted from the retina 
 (R) through the optic nerve 
 (on) to the visual center (vs), 
 thence through an association 
 fibre (ai) to the motor center 
 (mc). Here the movement is 
 initiated, the impulse traveling 
 further through the motor tract 
 (mt), anterior horn (ah), and 
 the motor nerve (mn) to the 
 muscle (M) which contracts. 
 
 The following example 
 will more clearly illus- 
 trate the process. When 
 a child's arm is pricked 
 with a knife, the arm is 
 withdrawn, the irritation 
 being transmitted to the 
 
 Fig. 4. 
 
 The explanation is directly con- 
 tained in the text. 
 
24 
 
 PSYCHE 
 
 Fig. 5- 
 The contraction of a muscle, M, 
 causes an irritation to be transmitted 
 from the muscle through an afferent 
 fibre of the motor nerve, mui, to the 
 anterior horn, ah, thence through the 
 motor tract, mti, to the motor center, 
 mc, where a motor impression is 
 produced. Hereafter a visual sensa- 
 tion may cause a movement. The 
 visual impulse travels from the re- 
 tina, R, through the optic nerve, on, 
 to the visal center, vs, thence through 
 an association fibre, ai, to the motor 
 center, mc, and further through the 
 motor tract, mt, anterior horn, ah, 
 motor nerve, mn, to the muscle, M, 
 which contracts. 
 
 muscles of the arm along the 
 reflex arc described (Fig. 5). 
 The withdrawing of the arm is 
 not a voluntary movement, it 
 ensues also when the child is 
 asleep. The irritation through 
 the pricking is conveyed also to 
 the center of sensibility (sc) 
 and leaves here an impression 
 of pain. If the child has seen 
 the knife, a sense impression, 
 the image of the knife, is simul- 
 taneously established in the 
 visual center (vs). Thereafter 
 when the child merely sees the 
 knife approaching its arm, it 
 pulls the arm away. It per- 
 forms a voluntary movement, 
 it acts intelligently, while the 
 
 withdrawing of the arm when it was first pricked with 
 
 the knife, was merely a reflex movement. 
 
 Fig. 5 
 
PSYCHOLOGY 25 
 
 Every movement originating in the brain, like the 
 one just described, is a volitional movement. Volitional 
 movements constitute the will. They take place, as ex- 
 plained above, only after sufficient motor images have 
 been stored up in the motor center through frequent 
 reflex movements, and the resistances in the motor tracts 
 have been diminished. 
 
 Sometimes will is expressed not by executing, but 
 by suppressing movements, although the incitement to 
 perform them is present, for instance, by suppressing a 
 painful outcry while suffering pain. 
 
 From the preceding explanations results the follow- 
 ing definition of will. Will is the capability of re enforc- 
 ing motor images so that movements take place, and also 
 of weakening motor images so that movements are sup- 
 pressed. 
 
 According to the foregoing interpretation of voli- 
 tional movements or will, all actions of man and animals 
 would take place in an entirely regular manner following 
 definite fixed causes physically preestablished. Freedom 
 of the will would be inconsistent with this interpretation. 
 Some philosophers, however, maintain that will is free. 
 They either give another explanation of will, or attempt^ 
 somehow or other, to bring their view into conformity 
 with the above interpretation — indeterminism. But even 
 the adherents of this doctrine must admit that there is 
 an indisputable delimitation of freedom of the will. The 
 latter is particularly lacking in many morbid mental con- 
 ditions. When a movement can be demonstrated to 
 originate from morbid factors, it is an action executed 
 in a state of want of freedom of the will. From a med- 
 ical point of view freedom of the will is excluded in all 
 actions which are founded on a psychopathological basis. 
 
26 PSYCHE 
 
 Chapter XL 
 NATURAL IMPULSES, INSTINCTS. 
 
 Psychical phenomena, also worthy of our attention, 
 which pertain to the activity of the will, are the natural 
 impulses or instincts. 
 
 According to Wundt a simple volitional action, i. e., 
 such an action that has only a single motive, is an ''im- 
 pulse action." Such actions, originating from, or having 
 their motive in, certain sensations and sense feelings, are 
 termed instincts. The alimentive and generative organs 
 mainly give rise to those sensations and feelings which 
 call forth instincts. The individual ''impulse actions" 
 arise from stimuli, external or internal. 
 
 To explain the complex character of many instinc- 
 tive actions, generically acquired qualities of the nervous 
 system must be assumed in consequence of which con- 
 genital reflex mechanisms are set in motion and, without 
 previous training, carry out complicated actions when- 
 ever stimuli act upon specific organs. 
 
 Instances of instincts in animals are the impulses 
 of many animals to build houses and nests, as with 
 beavers, birds, ants; or else to live in matrimony, mon- 
 ogamic or polygamic, as with many birds; or else to 
 form social communities, as with bees, ants, termites. 
 
 The view that instincts are peculiar to animals and 
 lacking in man is erroneous. On the contrary, instincts 
 are very numerous in man. Especially the alimentive 
 and generative instincts are innate in man as well as in 
 animals. The human instincts are most easily recog- 
 nized in infancy and childhood. Sucking is a well de- 
 veloped instinct of the new-born. By instinct the infant 
 cries at discomfort, pain, or solitude, and smiles at be- 
 
PSYCHOLOGY 27 
 
 ing caressed. Imitation is a typical instinct, the imita- 
 tive actions being entirely unpremeditated and ensuing 
 whenever certain perceptions take place. The earliest 
 period of life excepted, this instinct is common to all 
 ages of man. The young child imitates gestures and 
 sounds. At a later age it repeats the games of others. 
 The imitativeness of adults is seen in the tendency to 
 speak and behave like others, to yawn or laugh when 
 others do so, and so on. Another human instinct is the 
 repugnance towards certain substances, such as blood, 
 pus, dejecta. A strong human instinct is the impulse to 
 propagate the species, which finds its expression in the 
 various manifestations of love; and the strongest in- 
 stinct is the impulse of self-preservation, which causes 
 man to prefer the most miserable life to death. 
 
 Chapter XII. 
 
 CONSCIOUSNESS. 
 
 In every-day language the term consciousness desig- 
 nates various mental states which have only little rela- 
 tion to one another. There is a difference, for instance, 
 between saying, we are in a state of consciousness, and 
 we have self -consciousness. The definition of con- 
 sciousness, therefore, is very difficult. Some maintain 
 that it is impossible to define consciousness. But even 
 though a definition of the term cannot be exhaustive, yet 
 for our purposes the following explanation will suffice. 
 Consciousness is that mental state in zvhich we are en- 
 abled to receive sensations, to gather perceptions, to 
 operate zcith them, and to act at zvill. An unconscious 
 person is unable to experience sensations, to acquire per- 
 
28 PSYCHE 
 
 ceptions, and to act intelligently; he does not see, nor 
 hear, nor execute voluntary movements. Self-conscious- 
 ness, on the other hand, is the capability of separating 
 one's own individuality from the external world, of rec- 
 ognizing it as something distinct, something special. An 
 individual receives cognizance not only of external things, 
 but also of his own body, for instance of the attitude of 
 his limbs, i. e., he has self -consciousness. 
 
 Self -consciousness includes orientation, which de- 
 pends on memory and constitutes the knowledge of our 
 relation to our environment and our comprehension of 
 time and space. 
 
PART II. 
 
 GENERAL PATHOLOGY OF THE 
 MENTAL FUNCTIONS 
 
SECTION I. 
 
 PATHOLOGY OF FEELING OR OF THE 
 AFFECTIVE SPHERE 
 
 Chapter XIII. 
 MORBID DEPRESSION. 
 
 Morbid depression is a very frequent pathological 
 alteration of the mood. It has great similarity with 
 normal mental dejection, from which it is sometimes 
 hardly distinguishable ; at most it differs from it through 
 its intensity. Unmistakable criteria, therefore, are re- 
 (juired to confirm the morbidity of a depressed state of 
 mood. There are three such criteria. One of them 
 consists in the absence of any external cause for the 
 depression. The experiences of the patient preceding 
 liis depression do not contain anything on which it may 
 be founded. The cause of the depression is an internal 
 one, it lies within the patient himself. Some patients 
 are even able to state that nothing disagreeable has oc- 
 curred to them, that they do not know what may be the 
 cause of their sadness. If apparently there be any cause, 
 it is entirely inadequate to explain the intensity of the 
 depression. This disproportion between cause and effect 
 is generally overlooked by the inexperienced. 
 
 The second criterion is the unusually long duration 
 of the depression. Misfortunes often happen in life 
 j^bout which one cannot be consoled in the beginning. 
 
32 PSYCHE 
 
 But a sane person, after a comparatively short time, be- 
 comes reconciled to the new state of affairs, grows 
 calmer, and regains his former mental disposition. 
 Morbid depression, however, lasts for weeks and months, 
 and even years, and, what is especially pathognomonic, 
 increases with time instead of decreasing as is the case 
 with normal mental dejection. 
 
 The third criterion is expressed by the saying: 
 ''Sublata causa tollitur effectus." If one is in a sad 
 mood on account of pecuniary losses, his sadness disap- 
 pears when the lost sum is restored. An insane patient, 
 however, who mourns for having lost his fortune, will 
 continue to do so even when millions are presented to 
 him, and his mournfulness will not abate, but rather in- 
 crease at the announcement that he has recovered his 
 lost fortune. It is impossible to remove the morbid 
 depression by external reasons and by persuasion and 
 consolation. Solace and kind words may bring about 
 an appeasement, but it is only apparent or at least very 
 brief. Proud of the success obtained through his clever 
 words of consolation, the comforter comes to his patient 
 on the following day and finds that he has not only 
 achieved no permanent good result, but has made things 
 even worse, the patient being now more depressed than 
 ever. 
 
 The three criteria to determine the morbidity of a 
 depressed mood may be summed up as follows : Depres- 
 sion of mood is pathological, if it is not explained by any 
 cause, or only an insufficient reason is advanced; if it is 
 not mitigated by time, but lasts unusually long and even 
 increases with time; finally, if it cannot be abolished by 
 removing the ostensible cause, by external reasons, by 
 words of consolation. 
 
GENERAL PATHOLOGY 33 
 
 This mood or affective state is called the melan- 
 cholic affective state and is characteristic of melancholia. 
 
 Morbid depression increases now and then to an 
 emotional attack of anxiety and fear. The patient, until 
 now apathetic, insensible, and indifferent, becomes greatly 
 agitated, runs about hither and thither, wailing loudly 
 about his fancied misfortune. These attacks are tran- 
 sitory, and the patient lapses into the former depression. 
 
 Chapter XIV. 
 
 INFLUENCE OF MORBID DEPRESSION ON THE 
 PSYCHICAL FUNCTIONS. 
 
 The symptoms of mental disease are in constant 
 interrelation. A change in one psychical province modi- 
 fies the others. In this interrelation we have a ready 
 means to detect malingerers and an important factor for- 
 ensically. It is, therefore, advisable always to consider 
 the various symptoms of mental disease in their mutual 
 relations. 
 
 The psychical functions undergo a considerable 
 modification through morbid depression of the mood. 
 
 The ideational process, the coming and going of 
 the memory images, is retarded during pathological de- 
 pression. The sphere of ideas is restricted, some ideas 
 are not at all accessible to the patient. 
 
 From the retardation of the ideational process re- 
 sults an impariment of memory. The patient cannot 
 recollect many events at all or only with great difficulty. 
 The memory images that can be reproduced are such as 
 have been brought about by painful sensations (pp. 
 19-20). 
 
 A patient in morbid depression is unable to per- 
 
34 PSYCHE 
 
 ceive correctly. His perceptions are composed of gloomy, 
 woeful memory images. The patient imagines himself 
 to be lost forever, considers his present circumstances 
 and his future in a most unfavorable light, and thus 
 arrives at delusions. 
 
 The volitional manifestations of the patient are 
 diminished in frequency, his energy is reduced. His 
 movements are few and sluggish, he prefers to sit qui- 
 etly on one spot. Sometimes he even fails to carry out 
 the movements required for taking- food and for other 
 physical needs. 
 
 When however the patient is seized with an emotion 
 of anxiety, the psychical functions assume a different 
 form (p. 33). While until then he did not give expres- 
 sion to any ideas, being silent, unconcerned, apathetic, 
 he now runs about quickly, wringing his hands and wail- 
 ing aloud. He complains of a distressing pressure over 
 the chest — the so-called precordial anxiety. He tries 
 to get a hold of all kinds of dangerous instruments to 
 injure himself and others. In this way it appears as 
 though the ideational process were accelerated and the 
 sum of ideas increased. In reality, however, it is one 
 and the same^ idea which always returns while the state 
 of agitation lasts. The will power is increased, the 
 patient in his anxiety exhibiting great energy and force. 
 
 Chapter XV. 
 
 MORBID EXALTATION. 
 
 The opposite of morbid depression of the mood is 
 }]iorhid exaltation. The patient maintains he is in ex- 
 cellent circumstances, hale and hearty, rich like Croesus, 
 
GENERAL PATHOLOGY 35 
 
 and his future roseate. He is remarkably cheerful and 
 inclined to pun and joke. The criteria for morbid de- 
 pression (pp. 31-32) are also applicable in establishing 
 the morbidity of an exalted mood. It is even more diffi- 
 cult to find an external cause which would explain the 
 great cheerfulness of the patient. For the happy events 
 of life are, indeed, much rarer than the untoward expc- 
 periences. The second criterion of morbid depression 
 (p. 31) is also more striking in morbid exaltation. If 
 a fortunate event has put a sane person in an extremely 
 joyful frame of mind, he regains his mental equilibrium 
 after a comparatively brief time. Morbid exaltation, 
 however, lasts unabated for weeks and months. The 
 third criterion (p. 32) also comes into consideration. It 
 is impossible to drag the patient down from his heaven 
 of bliss. If one Job's news after the other be conveyed 
 to him, his cheerfulness cannot be lessened. If one were 
 to tell the patient that his future looked unfavorable, he 
 would laugh at him or break out into a rage against the 
 bearer of the ill tidings. But the anger is forthwith 
 replaced by the former cheerfulness. This affective state 
 is called the maniacal affective state and is characteristic 
 of mania. 
 
 Chapter XVI. 
 
 INFLUENCE OF MORBID EXALTATION ON THE 
 PSYCHICAL FUNCTIONS. 
 
 The ideational sphere, memory, perception, voli- 
 tional activity, undergo a marked alteration through the 
 maniacal affective state. The course of ideas is accele- 
 rated, one memory image seems to drive the other away, 
 
36 PSYCHE 
 
 and, what has appropriately been termed "flight of ideas," 
 is brought about. The contents of the ideas are of a 
 joyful nature. The patient easily recollects the events 
 of his life, but only the fortunate ones occupy his mind 
 (pp. 19-20). He sees everything in a favorable light, his 
 perceptions have a friendly, cheerful character. He thus 
 judges his circumstances wrongly and overestimates his 
 powers, i. e., he arrives at delusions. These are just the 
 opposite of the melancholic delusions. The volitional 
 acts are increased in frequency. The energy is enhanced 
 with respect to the application of gross motor power 
 (p. 83), but diminished in regard to persistence. In 
 overcoming obstacles the patient may use great force, 
 but he is unable to carry out persistently a definite plan 
 of action, forgetting quickly what he has just intended 
 to do, owing to flight of ideas. Suddenly a new thought 
 flits through his mind, and the plan determined upon is 
 immediately abandoned. 
 
 Chapter XVH. 
 
 BARRENNESS OF THE AFFECTIVE SPHERE; 
 WANT OF ALL PSYCHICAL FUNCTIONS. 
 
 The desolation or barrenness of the affective sphere 
 consists in the lack of feelings, of affective tones. It is 
 characteristic of idiocy. Aside from the extreme emo- 
 tions, the highest joy and the deepest sadness, the sane 
 person is possessed of an almost unlimited gammut of 
 affective tones which, increasing with his experiences, 
 show innumerable gradations. This great variety of 
 affective tones is lacking in the idiot. He is either con- 
 
GENERAL PATHOLOGY 37 
 
 stantly indifferent, or angry, or joyful, or depressed. 
 The finer intermediate grades of feeling are missing. He 
 has no conception of filial affection, of friendship, of 
 patriotism, of feeling of honor or shame, and so on. 
 Emotions, however, appear very readily, and surpass in 
 intensity the emotions of normal individuals. A sane 
 person in an emotion of sadness never displays such 
 intense expression of pain as the idiot. When an indi- 
 vidual manifests the most violent anger at the slightest 
 inconvenience, we are justified in suspecting that we are 
 dealing with an idiot. 
 
 The desolation of the affective sphere is not always 
 congenital, as in idiocy, but may be also acquired. The 
 acquired barrenness of the province of feeling is the 
 consequence of a psychosis or represents its terminal 
 stage. A person whose mind would show the most deli- 
 cate reactions to all kinds of influences may become 
 entirely dull after having passed through a psychosis. 
 He takes no interest in his friends, the fate of his near- 
 est relatives does not concern him, and he is indifferent 
 to his own lot. Some patients are aware of the devasta- 
 tion of their affective sphere, of the defective reaction of 
 their mind, but cannot help it. They complain of not 
 possessing the same feelings they used to, and reveal to 
 those around them that "their mind and heart are dead- 
 ened." 
 
 Here may be mentioned the condition called stupor 
 and characterized by an almost complete standstill of all 
 psychical functions. Feelings and emotions are wanting, 
 and there is hardly any intimation of an idea. The 
 patients are as if inanimate. Their limbs remain in any 
 position given to them, although such position may be 
 disagreeable or even painful. 
 
38 PSYCHE 
 
 Chapter XVIII. 
 IRRITABLE AFFECTIVE STATE. 
 
 Contrary to the barrenness of the affective sphere 
 is the irritable affective state. There are individuals who 
 respond too readily to stimuli, to whom even the ordinary 
 sense perceptions cause discomfort and even pain. A 
 flash of light makes their eyes ache, a strong sound hurts 
 their ears. 
 
 Another kind of increased irritability consists in un- 
 usual duration and intensity of the emotions. It is met 
 with in those tainted by heredity and in idiots. Such 
 individuals, at the slightest cause, may fall into a state 
 of great affliction lasting exceedingly long and sometimes 
 ending in unexplainable suicide. Such emotions are not 
 interrupted by a shock as has been observed in a patient 
 who was in such a frame of mind. He fell into the 
 water and was pulled out of it in an unconscious condi- 
 tion. Notwithstanding this violent shock his emotional 
 attitude was unchanged upon regaining consciousness. 
 
 Chapter XIX. 
 
 PERVERSE FEELINGS. 
 
 Perversities of the affective sphere are not infre- 
 quent. They are met with chiefly in idiots and epileptics. 
 The patients, in certain circumstances, do not react in a 
 normal manner, the affective tones corresponding to these 
 occasions being perverse or absent. Some patients do 
 not hesitate to take into their mouths the most nauseating 
 things. This perversity has been called coprophagia. 
 The patients eat their own faeces and those of others, 
 
GENERAL PATHOLOGY 39 
 
 drink their urine. Sometimes such perverse acts are 
 called forth by delusions. The patients, for instance, 
 imagine that they lose strength with their urine, that by 
 drinking it they would be better enabled to defend them- 
 selves against the plots of enemies. Coprophagia is a 
 pathognomonic sign of insanity, and the statement has 
 correctly been made that coprophagia alone suffices to 
 establish the diagnosis insanity beyond doubt, the most 
 cunning malingerer being unable to swallow his own 
 dejecta (p. 27). 
 
 To a very slight degree similar phenomena are en- 
 countered physiologically. Pregnant women manifest the 
 strangest concupiscences. Odors ordinarily shunned offer 
 them pleasurable sensations, etc. 
 
 Some patients lack the feeling of shame. They are 
 not in the least ashamed to denude themselves in the 
 presence of others, to speak of sexual matters without 
 the slightest reserve, to masturbate openly, etc. The ten- 
 dency of some patients to indulge in obscene language — 
 coprolalia — or indecent gestures is due chiefly to the 
 want of the feeling of shame. 
 
 Morbid feeling underlies the compulsory ideas 
 (p. y2). This is easily comprehensible especially in the 
 case of those compulsory ideas which appear as morbid 
 fears — the so-called phobias — (pp. 70-71 ) . Patients labor- 
 ing under agoraphobia, on reaching a public square or 
 street, are seized with great fear so that they are unable 
 to cross it. Some patients succeed to pass the street by 
 certain devices, as by grasping firmly somebody's hand, 
 or by getting a hold of a carriage, or by fixing their eyes 
 on a certain object on the opposite side of the street, 
 unremittingly staring at the object for a while, and then 
 suddenly darting towards it. 
 
40 PSYCHE 
 
 Other examples of morbid fears are contained in 
 the chapter on compulsory ideas (70). 
 
 Another perverse feeling is perverse sexuality. It 
 is chiefly congenital and rarely acquired. Homosexuality 
 is its most frequent and conspicuous type. It consists 
 in aversion to the other sex and inclination to one's own 
 sex. In men it leads to pederasty and produces complete 
 impotence towards the female sex. 
 
SECTION IL 
 PATHOLOGY OF IDEATION 
 
 Chapter XX. 
 
 MORBID RETARDATION AND ACCELERATION OF 
 THE IDEATIONAL PROCESS. 
 
 The anatomic connection of the sensory elements in 
 the brain (pp. 8-10) renders the association of ideas or 
 memory images possible. When in one manner or an- 
 other a memory image, stored up long ago as an impres- 
 sion in a sensory element, is awakened, many other mem- 
 ory images are called forth, one after the other, from 
 cerebral elements which are associated with the first one. 
 In this way a constant play of ideas is going on, called 
 the ideational process. 
 
 The ideational process may be morbidly retarded, 
 less ideas appearing in a unit of time than normally. The 
 retardation of the ideational process is the usual symptom 
 of melancholia and is due to depression of mood. The 
 association is difficult, certain memory images cannot be 
 reproduced (pp. 19-20, 33). With this delay of the 
 course of ideas is connected an impairment of memory 
 The retardation of the ideational process is also met with 
 after psychoses. Some insanities terminate with such a 
 devastation of the ideational sphere that a great part of 
 the impressions stored up in the brain cortex seems to 
 be entirely wiped out, and the patient's wealth of expe- 
 riences lost. 
 
42 PSYCHE 
 
 The opposite of retardation is morbid' accelera- 
 tion of the ideational process. Some patients pro- 
 duce an immense number of ideas in a unit of time. 
 Ideas just intrude upon them. One idea rapidly follows 
 the other, giving rise to the s^anptom appropriately 
 termed "flight of ideas" (pp. 36, 19-20). The ac- 
 celeration of the ideational process is the usual symp- 
 tom of mania. The memory appears to be improved, 
 the patient disposing of his stored up experiences with 
 great facility. On the other hand, he is unable to de- 
 velop his thoughts in the same way as a sane person, for 
 he cannot retain an idea long enough, deviating quickly 
 from the train of his thoughts. All his perceptions are, 
 therefore, characterized by superficiality. 
 
 Chapter XXI. 
 
 HALLUCINATIONS. 
 
 The hallucinations form a very important morbid 
 alteration in the ideational sphere. A few preliminary 
 remarks are necessary for a clear definition of the term. 
 It has been said a sensation to which no external object 
 corresponds, is a hallucination, for instance, seeing an 
 object which is not present. Related to this is tlie illu- 
 sion which has been defined as a sensation to which an 
 external object corresponds, but not in the same form 
 as perceived by the patient. For instance, if the patient 
 sees a person who actually stands before him, and the 
 person appears to him to have fiery eyes or to have his 
 head surrounded by a halo, he has an illusion of the visual 
 sense. This explanation of hallucination is correct only 
 
GENERAL PATHOLOGY 43 
 
 inasmuch as a hallucination is indeed a sensation not 
 originating from an external object, but the explanation 
 is not sufficient since it would justify designating every 
 memory image as a hallucination. For a memory image is 
 also a sensation not originating from an external object. 
 A more exhaustive definition must, therefore, be sought. 
 It is conceivable that a sensation may be neither induced 
 from the periphery, nor brought about by way of asso- 
 ciation like a memory image (p. 9), but may originate 
 in the brain cortex at the place where the impressions 
 are stored up. If a pathological irritation be active at 
 this place, it will cause sensations to arise which will 
 have no relation to an external object nor to the associa- 
 tion paths. To illustrate the point in a trivial manner, 
 suppose it were possible to prick, with a needle, certain 
 parts of the brain cortex. The individual would have 
 sensations called forth by this artificial injury to his 
 brain. These sensations would correspond to the im- 
 pressions stored up in the injured cerebral part, and 
 would appear to him to come from the periphery, from 
 a sense organ, for he is unaware of the injury inflicted 
 upon his brain. Now, substitute for this artificial injury 
 a pathological irritation, such as a local inflammation of 
 the cerebral cortex, and it will readily be seen that in the 
 consciousness of the individual sensations must arise 
 which he believes to come from a sense, but which in 
 reality have no relation to the periphery nor to the asso- 
 ciation paths. The definition of hallucination is, there- 
 fore, the following: Every sensation originating, ac- 
 cording to the patient's conviction, from a sense organ, 
 but in reality not called forth at the periphery, further 
 every memory image arising in consciousness not by way 
 of the association paths, is a hallucinatory image; every 
 
44 PSYCHE 
 
 perception composed of hallucinatory images (p. 12) is 
 a hallucinatory perception or simply a hallucination. 
 
 Illusion is closely related to hallucination. In every- 
 day language this word is often used to express an in- 
 adequate perception. We sometimes say one has been 
 under an illusion when, for instance, walking on the 
 street he believes to see an acquaintance, but on approach- 
 ing finds that it is some one else. In a psychiatrical sense, 
 however, this is no illusion, but merely a superficial per- 
 ception. Illusion, as a medical term, signifies an actual 
 sensation during which the patient hallucinates, a real 
 perception interfered with by the supervening of a hallu- 
 cination. One who is subject to hallucinations is liable 
 to have illusions at any moment. If he were put into a 
 dark room where he sees nothing and hears nothing, he 
 would have pure hallucinations. But when he is on the 
 street where he sees objects and hears noises, his hallu- 
 cinatory sensations will combine with actual sensations 
 to form illusions. He will see, for instance, persons, but 
 in cadaverous appearance or in queer colors ; he will hear 
 noises, but terribly loud, etc. It is evident that such a 
 perception is very different from what is sometimes called 
 illusion in ordinary language. If one imagines he sees 
 an acquaintance and finds later that he has been mistaken, 
 this is merely a deficient observation, the capability of 
 the senses not having been sufficient for the right per- 
 ception. In the hallucination as well as in the illusion 
 one hallucinates, but in the latter at the moment of an 
 actual sensation. A patient, for instance, stated that he 
 saw on the street a person with a golden halo around his 
 head. This was an illusion; he saw somebody, and in 
 the same moment he hallucinated in the visual sense. 
 
 Hallucinations occur in all the senses, most fre- 
 
GENERAL PATHOLOGY 45 
 
 quently in the senses of hearing and of sight. The aud- 
 itory hallucinations seem to be more frequent than the 
 visual hallucinations. 
 
 It is comprehensible that after the loss of a certain 
 sense, hallucinations relating to that sense can take place. 
 For the loss of a sense does not imply the extinction of 
 the impressions stored up in the brain through this sense. 
 The impressions remain in the cerebral cortex and may 
 give rise to hallucinations. And indeed, it is often ob- 
 served that patients with acquired blindness hallucinate 
 quite a good deal in the visual sense when suffering from 
 a psychosis. The same is the case with the sense of hear- 
 ing. But illusions can never occur in the sphere of a lost 
 sense. For illusions are combinations of actual and hal- 
 lucinatory sensations; the former, however, are done 
 away with by the loss of the sense. 
 
 According to a general biological law there is no 
 sharp limit between the normal and pathological. The 
 limit, geometrically expressed, is not a line, but a zone, 
 the so-called physiological latitude. This law applies 
 also to the distinction of normal memory images from 
 hallucinatory images. Between both there are gradual 
 transitions. In recollecting a shot the auditory memory 
 image is comparatively weak. It is far from having the 
 intensity of the auditory sensation actually received when 
 hearing the shot. But there are people in whom the 
 memory images are much keener than in the average 
 person. An ingenious musician remembers a melody 
 with great vividness, he almost hears it. Great artists, 
 thinking of the picture they want to paint, have it before 
 their very eyes. There are, therefore, even in sane 
 people considerable differences in the intensity of mem- 
 ory images. If, however, a pathological irritation be 
 
46 PSYCHE 
 
 active at the place where sense impressions are stored up, 
 images arise in consciousness as vivid as actual sensa- 
 tions. They are spoken of as hallucinations while this 
 term is not applied to the extremely vivid memory im- 
 ages of sane persons. For there is a great difference 
 between the two instances aside from the non-participa- 
 tion of the association paths in one instance and their co- 
 operation in the other. The sane person, be his memory 
 images ever so vivid, is still conscious that he is dealing 
 with nothing else but memory images, with ideas arising 
 very strongly within him. The diseased individual, how- 
 ever, does not recognize his memory images as such, but 
 believes to have actual sensations coming from the peri- 
 phery, from a sense organ. 
 
 Chapter XXII. 
 AUDITORY HALLUCINATIONS. 
 
 The auditory hallucinations are the most frequent. 
 For by the sense of hearing most of the experiences in 
 life are acquired. More auditory memory images are, 
 therefore, deposited in the cerebral cortex than memory 
 images obtained through any other sense. 
 
 Patients whose acoustic memory images are differ- 
 ent from the normal memory images of sound, are not 
 yet afflicted with auditory hallucinations. Between the 
 normal auditory memory images and auditory hallucina- 
 tions there are gradual transitions. Some patients com- 
 plain that a word or a melody which they are merely 
 thinking about appears to them very vivid. But their 
 memory images are still sufficiently faint, far from be- 
 ing equivalent to spoken words. The patients still know 
 
GENERAL PATHOLOGY 47 
 
 that another person cannot hear their memory images. 
 This is the first step leading to pathological conditions, 
 but still met with normally. In the next grade patients 
 say they hear their thoughts so loudly that they are under 
 the impression that others standing very near may also 
 hear them, but they are not as well perceptible as words 
 spoken aloud. Again other patients complain of their 
 thoughts becoming so loud that people passing by can 
 hear them. They maintain that their thoughts are re- 
 peated by others. Reading silently they hear everything 
 repeated as though others would read with them. But 
 although these acoustic memory images are of such in- 
 tensity that they are not distinguishable from actual au- 
 ditory sensations, the patients are yet conscious that they 
 are their own thoughts, i. e., they are still sensations 
 brought about by way of association. Other patients 
 finally assert they hear words originating from without, 
 and are certain that they are not their own individtial 
 thoughts. They have auditory sensations, the origin of 
 which they refer to the outside world, but which in re- 
 ality originate in their own brain cortex, at the seat of 
 tlie auditory sense impressions. Such patients, therefore, 
 are suffering from true hallucinatory sensations. The 
 last example illustrates purely pathological conditions, 
 while the preceding examples refer to the transitional 
 stages between the normal and pathological. 
 
 The auditory hallucinations show the same variation 
 in intensity as the normal sensations of hearing. One 
 maj hear something spoken in a whisper, or uttered 
 aloud, or something may be thundered into one's ear. 
 Likewise the auditory hallucinations vary. Their in- 
 tensity may be as slight as that of memory images of 
 hearing. The patients commence to notice that some- 
 
48 PSYCHE 
 
 thing is being ''suggested" to them. They are convinced 
 that it is no thought of their own, no memory image; 
 for it does not at all appertain to their thoughts, forms 
 no part of them. It appears to the patients that ideas 
 not their own are infused into their mind. They arrive 
 at the notion that suggestions are imparted to them by 
 a superior power, by God or the Evil One, according to 
 the contents of the suggestions. In the next grade hallu- 
 
 Fig. 6. 
 
 When the retina, R, is stimulated, the irritation is conveyed 
 through the optic nerve, on to the visual center, vs. It may- 
 travel further through the association path, ai, to the audi- 
 tory center, as, and call forth an auditory image. The in- 
 tensity of this image may be abnormal, but the way ai, by 
 which it has been awakened is used also under normal con- 
 ditions. 
 
 cinating patients say they hear words spoken in a whisper, 
 or at a great distance, or near by and in an ordinary tone 
 of voice. Other patients, finally, relate that words are 
 violently shouted into their ears, or they hear walls crash- 
 
GENERAL PATHOLOGY 49 
 
 ing with terrific din or the roar of cannons. These are 
 auditory hallucinations of greatest intensity. 
 
 Patients who complain about their thoughts becom- 
 ing loud are not diseased to the same extent as those 
 having pronounced hallucinations, even if the latter have 
 only the low intensity of memory images. For in the 
 first instance the patients have sensations which are noth- 
 ing else but memory images of unusual intensity and 
 come by a way also used under normal conditions (Fig. 
 6, ai) ; in the second instance, however, the sensations 
 of the patients arise in a cerebral part (as) where nor- 
 mally sensations never take their origin. 
 
 Chapter XXIIL 
 
 VISUAL HALLUCINATIONS. 
 
 Similar conditions prevail in the sense of sight. 
 Some persons assert that a picture which they are thinking 
 of appears to them as vivid as though they would really 
 see it. Yet they are conscious that it is merely a memory 
 image. This great vividness of the visual memory im- 
 ages represents the transition to pathological conditions. 
 In pronounced visual hallucinations the patients say they 
 see things before them which in reality are not present. 
 The visual hallucinations show the same gradations as 
 the auditory hallucinations. Some patients say something 
 flutters past their eyes, or they see shadows, things of 
 vague shape and indeterminate color, without form, flat, 
 hazy, gray. When the visual hallucinations are stronger, 
 the patients perceive persons and objects of distinct shape 
 and definite color, red, green, or blue. Such hallucina- 
 tions do not differ any more from actual sensations. 
 
50 PSYCHE 
 
 Other patients finally see flames, burning structures, 
 flashes of lightning, etc. These are visual hallucinations 
 of maximum intensity. 
 
 Visual deceptions different from those just men- 
 tioned are the following: Patients relate that they see 
 figures changing their sizes. In the beginning the figures 
 appear big, then they become smaller and smaller, and 
 at last they fade away entirely. In other patients the 
 apparitions are inverse. They begin to perceive animals 
 and things of minute size. After a while these change 
 into immense masses or huge monsters. With such hal- 
 lucinations is connected a perception of movement. When 
 a patient sees a figure growing bigger, he believes that it 
 approaches towards him; he notices something coming- 
 nearer and nearer until it finally penetrates into him. 
 Such deceptions give rise to the belief in devilry. An- 
 other visual deception consists in seeing a multitude of 
 things, of many threads, gnats, beetles, mice, etc. Some 
 patients see many objects in motion, rats jumping about, 
 insects fluttering, little men dancing, etc. (delirium tre- 
 mens, p. 260). 
 
 Chapter XXIV. 
 
 TACTILE, OLFACTORY, AND GUSTATORY HALLU= 
 CINATIONS. 
 
 Next in frequency are the hallucinations of the tac- 
 tile sense. Some patients tell of being gently touched, 
 of formication; others complain of intense pressure on 
 various parts of the body or of having been shot. Again 
 others report that the roof of their scull has been lifted 
 away and their brain is exposed; they beg pitifully not 
 to be touched on the head or shaken in any manner, 
 
GENERAL PATHOLOGY 51 
 
 Some patients feel as though dust were constantly falling 
 on them from the air, and cover themselves to prevent 
 it from reaching their body. Sexual deceptions are also 
 to be mentioned here. Female patients relate accounts 
 of having been criminally assaulted. 
 
 In the sense of smell hallucinations are frequently 
 met with. Some patients perceive cadaverous odors. 
 Such hallucinations lead the patients to the delusion of 
 being on a graveyard or of having eaten human flesh, 
 and the like. Other patients scent brimstone everywhere. 
 They bring this into relation to the devil who according 
 to folklore spreads a sulphurous odor. Other patients 
 again complain of smelling burnt stufY, such as singed 
 hair, etc. Also agreeable perfumes are perceived by 
 some patients. They imagine that they inhale an atmo- 
 sphere of a finer fragrance than others. 
 
 Regarding the sense of taste it is often difficult to 
 decide whether hallucinations attributed to it do not be- 
 long rather to the sense of smell. For when a patient, for 
 instance, says something has a putrid taste, this may also 
 be an olfactory deception. Frequently patients complain 
 that their food has a metallic taste, as of copper. Other 
 patients perceive a bitter, salty taste, etc. Gustatory hal- 
 lucinations may lead the patients to the delusion that 
 poison has been put into their food. 
 
 Chapter XXV. 
 
 SEQUELAE AND SYMPTOMS OF HALLUCINA= 
 
 TIONS. 
 
 A patient may hallucinate in more than one sense. 
 In delirium, for instance, hallucinations take place in all 
 the senses. It is evident that such a patient must become 
 
52 PSYCHE 
 
 entirely confused. For the things that he sees do not 
 exist, the words that he hears are not spoken, and so on. 
 One consequence of hallucinations, especially when they 
 are manifold, is, therefore, a state of confusion. Delu- 
 sions and violent acts form another important sequence 
 of hallucinations. The patient draws conclusions from 
 his hallucinations in the same manner as a sane person 
 from his normal sensations. When he hears abusive 
 words, he concludes that somebody is insulting him, and 
 is misled to commit an assault upon a supposed enemy. 
 Hallucinations have so great an effect upon the patient 
 that he obeys them more promptly than his real percep- 
 tions. Many offenses committed by the insane are to be 
 attributed merely to hallucinations. The reason that hal- 
 lucinations have a greater influence on patients than nor- 
 mal sensations is that the former are founded on patho- 
 logical processes, and these are often of greater intensity 
 than the normal sensational processes. While a patient 
 hallucinates his normal perceptions are forced into the 
 background. Just as a strong normal sensation causes a 
 person to direct his attention to the object producing the 
 sensation and to overlook everything else, so also a hal- 
 lucination, owing to its greater intensity, absorbs com- 
 pletely the attention of the patient and prevents him from 
 becoming aware of other sensations. This monopolizing 
 of the patient's attention characterizes hallucinations. In 
 the midst of a conversation we notice that all of a sudden 
 the patient assumes an air of pensiveness or absent- 
 mindedness and does not listen any more to the words 
 directed to him. This abrupt distraction is a fairly sure 
 sign that at this very moment hallucinations have arisen 
 in the patient's consciousness, attracting all his attention. 
 
GENERAL PATHOLOGY 53 
 
 Chapter XXVL 
 DELUSIONS. 
 
 The most important morbid phenomena in the idea- 
 tional sphere are the delusions. For by this symptom 
 more than by anything else the patients attract the atten- 
 tion of neighbors and relatives and are recognized as 
 insane. 
 
 Laymen care less for essential features of delusions 
 than for the casual sign that they often contain a palpable 
 absurdity. They are ready with their judgment when 
 they hear an irrational utterance. The physician cannot 
 assume such a standpoint. For otherwise he would be 
 unable to differentiate malingery from disease, which is 
 very important, especially in forensic matters. To be 
 able to detect the wiles of an impostor he must have a 
 more profound conception of delusions and must be 
 guided by unmistakable criteria. These are obtained by 
 considering the origin, the source of delusions, by prov- 
 ing that their genesis is pathological. 
 
 The principal source of delusions are hallucinations 
 and illusions. These impart to the patient certain notions 
 in the same way as a sane person draws conclusions from 
 his normal perceptions. The conclusions derived from 
 hallucinations and illusions represent delusions. An error 
 is far from being a delusion. One often errs in life, 
 owing to superficial observation or to lack of experience. 
 Only when a notion, be it true or not, can be shown to 
 have its origin in hallucinations, is it to be designated 
 as a delusion. Delusions may contain a truth. For ex- 
 ample, a patient took the notion that his father was dead, 
 which was not the case. According to laymen's concep- 
 tions this is at once a delusion. But the physician has to 
 
54 PSYCHE 
 
 prove first that the patient is suffering from hallucina- 
 tions before he is justified in assuming a delusion. The 
 importance of such a proof is seen by what followed. 
 After a lapse of some time the father died, and the son's 
 notion thus became true. Laymen would say the patient 
 was now free from his delusion, but from a psychiatrical 
 point of view the delusion is still present, although now 
 it contains a truth. 
 
 Another source of delusions lies in morbid altera- 
 tion of the affective state. Suffering from morbid de- 
 pression, the patient sees everything in an unfavorable 
 light, for only such memory images arise in his con- 
 sciousness which have been produced by painful sensa- 
 tions (pp. 20, 34). Working with such memory images, 
 he acquires sad perceptions. The presence and future 
 appear gloomy to him, he underestimates his capabilities 
 and his circumstances, believes himself to be despised 
 and persecuted, to be lost forever. These are delusions 
 of a depressive jiature. 
 
 On the other hand, when laboring under morbid 
 exaltation, only memory images of a cheerful character 
 arise in the consciousness of the patient (pp. 20, 36). 
 This leads him to conclusions which deceive him regard- 
 ing his powers, he overestimates his capabilities and his 
 circumstances. These are delusions of exaltation. 
 
 When, therefore, in a given instance it is possible 
 to demonstrate that a notion formed by the patient is 
 founded on hallucinations or illusions, or on a morbid 
 alteration of the affective state, this notion is to be con- 
 sidered a delusion. 
 
GENERAL PATHOLOGY 55 
 
 Chapter XXVIL 
 
 CLASSIFICATION, DIAGNOSTIC VALUE, AND 
 SEQUELAE OF DELUSIONS. 
 
 Formerly innumerable sorts of delusions were dis- 
 tinguished. Indeed, everybody produces delusions pecu- 
 liar to his character, education, and calling in life. The 
 delusions of the army officer, for instance, will differ 
 from those of the priest. To obtain a proper guidance in 
 the great variety of delusions it is best to classify them 
 so that the diagnosis of the psychoses may be facilitated. 
 Accordingly the following delusions may be distin- 
 guished: I. Delusions of grandeur ^Grossenwahn," 
 megalomania) ; 2. delusions of self -depreciation ("Klein- 
 heitswahn," micromania) ; 3. delusions of furtherance 
 ( "Forderungs wahn" ) , i. e., of being the object of favor 
 or bounty from persons in high position, through super- 
 natural powers, or even through propitious circumstances ; 
 4. delusions of grievance (''Beeintrachtigungswahn"), 
 i. e., of being wronged or of innocently suffering injuries. 
 Delusions may be fixed, i. e., irremediable, or they may 
 still be capable of correction. A distinction can also be 
 made according to the explanation which the patient ad- 
 vances for his delusions. A fairly plausible reason may 
 l)e brought forward by the patient for his delusions, or 
 he may give a very inadequate reason for them or no 
 reason at all. The latter are called absurd delusions. 
 
 This classification of the delusions is of great diag- 
 nostic value. All delusions of grandeur are characteristic 
 of maniacal excitatory states. In such conditions we 
 never fail to observe that the patient overestimates him- 
 self, his present circumstances, and his future. If he is 
 able to state some plausible reason for his exalted no- 
 
56 PSYCHE 
 
 tions, he is suffering from ordinary maniacal excitement, 
 but if no explanation is advanced by the patient for his 
 delusions of grandeur, paretic excitement or dementia 
 praecox is to be surmised; in other words, absurd delu- 
 sions of grandeur indicate general paresis or dementia 
 praecox. Something analogous applies to the delusions 
 of self -depreciation. They are pathognomonic of melan- 
 cholic states. If they are fairly well accounted for by 
 the patient, we are dealing with a melancholia of slight 
 intensity and of a comparatively favorable prognosis. If 
 however the delusions bear the stamp of absurdity, gen- 
 eral paresis or dementia praecox may be assumed. The 
 delusions of furtherance and of grievance are character- 
 istic of paranoia. 
 
 That the conduct of the patient is greatly influenced 
 by his delusions is evident. As the sane person is 
 prompted to act in conformity with his convictions, to 
 offer sacrifices for them, and not to abandon them with- 
 out good cause, so also a patient is prone, we may rather 
 say, compelled, to conform his actions to his delusions. 
 Before long he begins, driven by their compelling force, 
 to commit acts which bring him into conflict with his 
 neighbors. Owing to delusions, crimes of the worst sort 
 may be perpetrated by the patients. Such actions dic- 
 tated by delusions are to be regarded as performed in a 
 state of want of freedom of the will. For the physician 
 has to consider any action as involuntary which he can 
 demonstrate to originate from pathological factors 
 (p-25). 
 
GENERAL PATHOLOGY 57 
 
 Chapter XXVIIL 
 DIFFERENTIATION OF THE DELUSIONS. 
 
 Delusions of furtherance may be easily confounded 
 with those of grandeur, and delusions of grievance with 
 those of self-depreciation. An exact distinction is, there- 
 fore, required because of the diagnostic importance (p. 55 ) 
 of the different forms of delusions. This distinction 
 is obtained by inquiring into the role which the patient's 
 self, his ego, plays in the delusion. When, for instance, 
 the patient says he will soon ascend the throne of Brazil, 
 this assertion may be a delusion of grandeur as well as 
 of furtherance. If the patient maintains that he is able 
 to conquer the throne through his great wisdom and 
 power, he is laboring under a delusion of grandeur. It 
 is the patient's own self that is great and mighty. If 
 however he says he is descended from parents who have 
 a claim to the throne, he is suffering from a delusion of 
 furtherance. The essential element furthering the patient 
 lies in his birth. If a patient says he will obtain great 
 wealth because of being the protege of a powerful prince, 
 he has a delusion of furtherance. But if he maintains to 
 possess millions because, through his great cleverness, he 
 has discovered the art of making gold, he suffers from 
 a delusion of grandeur. If a patient says he has been 
 chosen by God to redeem the sinful world, he has a delu- 
 sion of furtherance. If however he maintains to possess 
 unlimited divine power enabling him to bring order and 
 rule into this wicked world, he is possessed by a delusion 
 of grandeur. 
 
 The same relation prevails between the delusions of 
 grievance and those of self-depreciation. Some patient 
 harbors the intention of suicide. He says he is exposed 
 
58 PSYCHE 
 
 to intolerable persecution so that he is disgusted with 
 life, that life has no attraction for him any more. To 
 say simply the patient suffers from a delusion of per- 
 secution would not clear up the diagnosis. We must 
 try to find out what the patient thinks of his own self. 
 If he says that he is unworthy, that he deserves no better 
 treatment from those around him, that persecutions still 
 worse ought to be his share, he labors under a delusion of 
 self-depreciation. For the patient's self plays a guilt- 
 laden role and is worthless and despicable. If however 
 the patient says that he is entirely innocent, that he does 
 not understand at all why he should be the object of 
 malicious oppression, he is swayed by a delusion of griev- 
 ance. For he still values his ego a great deal. 
 
 Chapter XXIX. 
 SYSTEMATIZED DELUSIONS. 
 
 When delusions of furtherance and of grievance 
 exist concomitantly, the diagnosis paranoia may be made 
 with more certainty than when the patient manifests only 
 one kind of these delusions. Between the two varieties 
 of delusions there is often a palpable contradiction which 
 the patient may be aware of and which he tries to ex- 
 plain away. The patient, for instance, says he will soon 
 ascend the throne of Brazil, to which he is entitled by 
 birth. He thus suffers from a delusion of furtherance. 
 At the same time he maintains to be maliciously perse- 
 cuted. This inconsistent assertion that so high a per- 
 sonage as a future emperor should be the object of op- 
 pression, is explained by the patient in the following 
 way: There are other pretenders to the throne who are 
 
GENERAL PATHOLOGY 59 
 
 trying to prevent him from obtaining his rights, who are 
 seeking after his life, and who are contriving all the per- 
 secutions which he is exposed to. This weighing and ad- 
 justing of different notions, this effort to solve apparent 
 contradictions between them, are called systematized de- 
 lusion. It is pathognomonic of paranoia. Patients labor- 
 ing under systematized delusions would retrospectively 
 change their whole past to bring it in accord with their 
 present notions. In this way arise the romantic tales 
 of some patients relating to their birth, their early youth, 
 their education, etc. (p. 178). 
 
 Chapter XXX. 
 
 FIXED DELUSIONS. 
 
 It is very important to have an exact knowledge of 
 the so-called fixed delusions, a diagnosis of great signifi- 
 cance being established when they are demonstrated. A 
 patient with fixed delusions is suffering from secondary 
 insanity, which forms the continuation or the incurable 
 terminal stage of primary insanity (pp. 181, 184). Since 
 so ominous a prognosis is furnished by the presence of 
 fixed delusions, an accurate understanding of what is 
 meant by the term is required. Many a delusion may 
 last very long, for weeks and months; still it is not a 
 fixed delusion. It may finally be supplanted by another 
 delusion or abandoned entirely after having been recog- 
 nized by the patient as a wrong notion. If however a 
 patient clings to a delusion for years, we would perhaps 
 be justified in regarding it as a fixed delusion. But the 
 duration of a delusion cannot be taken as a criterion for 
 its being fixed. For there is no essential point available 
 
6o PSYCHE 
 
 for establishing the limit of time beyond which a delu- 
 sion must have lasted to be justly considered a fixed delu- 
 sion. While some would find this limit in a few months, 
 others would not regard even several years as a sufficient 
 time limit. A more reliable criterion, therefore, is neces- 
 sary. This is readily found when the source of delusions 
 is taken into consideration. The absence of the factors 
 which produce delusions is an unmistakable sign that the 
 delusions are fixed. When there are no more hallucina- 
 tions and illusions, and the affective state of the patient 
 is entirely normal (pp. 53-54), and he still clings to his 
 former wrong notions, they have become fixed delusions, 
 the patient being mentally so enfeebled by the preceding 
 psychosis that he is unable to recognize his delusions as 
 such and to abandon them. Had the psychosis not term- 
 inated in mental weakness, the patient would have given 
 up his delusions. 
 
 Chapter XXXL 
 DISTURBANCE OF MEMORY IN GENERAL. 
 
 Memory is the capability of producing ideas by way 
 of association. For this end sensations must have been 
 received and must have left impressions in the sensory 
 elements of the brain cortex, these elements must be ana- 
 tomically connected with each other, and the association 
 paths must be conductive. 
 
 Manifold disturbances occur in the activity of the 
 memory. Some of them are especially worthy of note, 
 as the abnormally increased capacity of memory, hyper- 
 mnesia, and the diminished capacity of memory, hypo- 
 mnesia and amnesia. The capacity of memory is not the 
 
GENERAL PATHOLOGY 6i 
 
 same in different healthy persons, it varies even in one 
 and the same person according to the state of fatigue 
 or rest and according to age. In youth impressions are 
 more readily received and events more easily recalled, 
 in advanced age both these faculties decrease. As a 
 compensation the person, mature in years, aids his mem- 
 ory by understanding and reasoning, finds by inference 
 how an event probably came about. A young person, 
 for instance, can remember exactly that he did not make 
 a certain remark attributed to him ; a person advanced 
 in years may not be positive about this by virtue of his 
 memory, but by an operation of the understanding he 
 will arrive at the conclusion that such words could not 
 possibly have been uttered by him. 
 
 Chapter XXXIL 
 
 ABNORMALLY INCREASED CAPACITY OF 
 MEMORY. 
 
 In all maniacal states the capacity of memory is 
 temporarily increased, owing to the facility of associa- 
 tion (pp. 19-20, and Ch. 16, p. 35). It must be assumed 
 that in maniacal conditions many mental processes are 
 intensified. For this reason the resistance in the asso- 
 ciation paths is more easily overcome. When the 
 maniacal excitement is at an end, the increase of the 
 capacity of memory also ceases. This is not to be re- 
 garded as due to fatigue brought about by the enhanced 
 work of the memory during the preceding maniacal ex- 
 citement. For there are psychoses in which maniacal 
 states alternate very frequently, even daily, with melan- 
 cholic ones. In these cases we observe a lowering of the 
 
62 PSYCHE 
 
 capacity of memory with the beginning of the melan- 
 cholic state and a rising with the onset of the maniacal 
 excitement, both too prompt to be attributed respectively 
 to fatigue and restoration. 
 
 A patient in maniacal excitement is aware of the 
 improvement of his memory and thinks that he has be- 
 come more clever than he ever was. 
 
 Besides the transitory improvement of memory in 
 maniacal states there is a permanent hypermnesia which 
 is very remarkable. Individuals who are intellectually 
 backward and defective in their affective sphere may dis- 
 play, so to say as a compensation, increased capacity of 
 memory. Such compensation is often observed physio- 
 logically. The capacity of one organ is sometimes con- 
 ditioned by that of another organ or another group of 
 organs. After the extirpation of one kidney the other 
 accomplishes more than before. The organ left becomes 
 larger, hypertrophied, and its efficiency is greatly en- 
 hanced. If one sense has not been developed or has per- 
 ished, another sense becomes more efficient. The hear- 
 ing of those born blind is remarkably acute, and their 
 tactile sense perhaps more so. The blind know whether 
 they are approaching a wall; one may say they "hear" 
 the wall, and this probably by the resonance of their 
 steps becoming stronger with the approach towards the 
 wall. Something analogous applies to the capacity of 
 memory in individuals whose intellectual development 
 has been arrested. As a compensation for the deficit in 
 other mental faculties the memory vicariously possesses 
 increased capacity. 
 
 The permanent hypermnesia has another basis than 
 the transitory one of the maniacs. It is not founded on 
 the facility of the association, but on the sensations leav- 
 
GENERAL PATHOLOGY 63 
 
 ing more readily impressions in the cerebral cortex than 
 is normally the case (pp. 7-8). It is astonishing what a 
 wonderful memory for the most unimportant trifles is 
 manifested by these patients. In school the teachers are 
 surprised about their faculties. They know by heart 
 almost everything they have read. In the elementary 
 schools they often make excellent progress, and even in 
 the higher schools they may distinguish themselves. 
 Simply by reproducing the judgments of others they 
 create the impression of being highly intelligent. Indi- 
 viduals with such awe-inspiring memories are like a 
 book, like a dictionary. We may say they decorate 
 themselves again and again with false plumes. 
 
 Such individuals may be recognized as mentally 
 defective only by deficiency of understanding and char- 
 acter (Ch. 82, p. 199). 
 
 When judging individuals with exceptionally great 
 power of memory in legal matters it is necessary to take 
 into consideration the pathologically enhanced capacity 
 of memory. Children with wonderful memories must 
 not be regarded at once as highly gifted. Especially 
 when a person coming from a family in which insanity 
 has prevailed displays an exceedingly powerful memory, 
 his mental health ought to be well taken care of. For 
 it is to be borne in mind that just those tainted by her- 
 edity and endowed with remarkable memories have a 
 strong predisposition to mental disease. 
 
 The abnormally increased capacity of memory just 
 described, which is met with in idiots, subsists all through 
 life provided no acute psychosis supervenes. 
 
64 PSYCHE 
 
 Chapter XXXIII. 
 DIMINISHED CAPACITY OF MEMORY. 
 
 In contrast to the maniacal states, the capacity of 
 memory is reduced in all melancholic conditions, owing 
 to the difficulty of association (pp. 19-20, 33). This 
 impairment of memory is transitory, ceasing with the 
 disappearance of the depressed mood. 
 
 Permanent reduction of the capacity of memory, 
 hypomnesia or amnesia, may be based on the sensations 
 failing to leave impressions in the brain cortex (pp. 7-8). 
 To some extent this is physiologically the case in ad- 
 vanced age. Some things, as names, numbers, do not 
 "cling" any more. Pathologically the failure of the 
 sensations to leave impressions occurs in premature and 
 in excessive senescence. The patients perceive some- 
 thing, and in the next moment they do not know any- 
 thing about it. They peruse the newspaper, and yet they 
 do not know what they have read. When a relative or 
 a friend, after long absence, comes into their home, they 
 embrace him joyfully. When thereupon they leave the 
 room for a while, they forget everything, and on enter- 
 ing the room again and noticing the friend, their joy 
 bursts out anew, as if they would see him for the first 
 time. This experiment may be repeated several times, 
 and in this way such patients may be made to enjoy 
 again and again the pleasure of seeing a dear friend after 
 long absence. 
 
 Diminished capacity of memory based on the same 
 cause as the hypomnesia of senility is met with in 
 paretics and in patients suffering from secondary de- 
 mentia. The patients hear, see, etc., but the sensations 
 leave no impressions, 
 
GENERAL PATHOLOGY 65 
 
 Another form of amnesia is caused by destruction 
 of impressions through an acut^ psychosis. Memory 
 suffers through a mental disease in the same way as 
 through actual loss of brain substance. Impressions of 
 the sensations are, somehow or other, formed in the 
 brain cortex — such a hypothesis is absolutely indispens- 
 able. Hence an operation on the cerebral cortex, caus- 
 ing loss of brain substance, will necessarily obliterate a 
 certain sum of impressions. The individual operated 
 upon is by no manner of means able to reproduce the 
 lost impressions. At best he can acquire them anew by 
 experiencing again the corresponding sensations. Such 
 a condition is actually created by apoplexies. If the de- 
 struction by hemorrhage of brain substance has taken 
 place in that cerebral part where the auditory images 
 are stored up, aphasia is the result. The patient is un- 
 able to speak for want of word impressions, the repro- 
 duction of which constitutes speaking. After the path- 
 ological process has come to an end and cicatrization of 
 the injured cerebral part has come about, the lost audi- 
 tory impressions may be acquired anew. Such extinction 
 of impressions occurs also in acute mental diseases with- 
 out hemorrhage or any other demonstrable injury to the 
 brain cortex. 
 
 In general paresis both forms of amnesia mentioned 
 above are met with. The sensations fail to leave im- 
 pressions, and impressions are actually destroyed through 
 gross pathological processes. 
 
 A third form of amnesia occurs in diseases asso- 
 ciated with disturbance of consciousness. The memory 
 at any rate is dependent upon the lucidity of conscious- 
 ness and is in direct proportion to it. In light slumber 
 events are not remembered as well as in a waking state, 
 
66 PSYCHE 
 
 Patients in an unconscious condition are unaware of 
 what is going on around them, do not acquire percep- 
 tions, and cannot make use of their faculty of memory. 
 After awaking they cannot remember anything that has 
 transpired during the unconscious state. 
 
 Periods of unconsciousness are frequent in epilepsy. 
 After a convulsive seizure the patients have no knowledge 
 of what has been going on during the attack; they even 
 do not know that they have had an attack, finding it out 
 only through some injury received in their unconscious 
 condition, as a bite on the lips or tongue or a bleeding 
 wound. 
 
 Epileptic patients are subject to spells of disturbance 
 of consciousness without convulsions. These periodic 
 epileptic spells are the so-called psychic equivalents of 
 the completely developed epileptic attacks (pp. 243-244). 
 The patients do not fall down, seized with convulsions, 
 but walk about and even perform complicated actions, 
 sometimes of a dangerous character, without being aware 
 of it — automatism. These automatic states may last a 
 long time, several days and weeks. When the patients 
 regain their normal consciousness, they cannot remember 
 any events that may have taken place during the spell. 
 There is a perfect gap of memory for the entire duration 
 of the spell. 
 
 The amnesia of the epileptics is of great moment 
 in forensic matters. If an epileptic has committed a 
 criminal act during a psychic equivalent, it is of con- 
 siderable importance for the medico-legal expert to de- 
 monstrate that the defendant has a gap in his memory. 
 For this would establish the fact that he is subject to 
 psychic equivalents and would render him irresponsible 
 during these periods. 
 
GENERAL PATHOLOGY (^y 
 
 A similar amnesia and gaps of memory are met 
 with in patients suffering from other diseases in which 
 spells of loss of consciousness occur, as in hysterical 
 patients. 
 
 Chapter XXXIV. 
 SOME PECULIAR DISTURBANCES OF MEMORY. 
 
 A remarkable impairment of memory occurs after 
 attempts at suicide through hanging. It is evident from 
 the foregoing chapter that the patient is unable to re- 
 member anything that has taken place during the time 
 of unconsciousness. But what is rather strange is that 
 he cannot remember what has immediately preceded 
 the suicidal attempt. Thus he does not know what im- 
 plement he has made use of to hang himself. This form 
 of amnesia can be produced experimentally. When the 
 carotid arteries are compressed, the individual experi- 
 mented upon quickly loses consciousness (p. 5). When 
 the compression ceases, consciousness returns. The in- 
 dividual cannot remember the incidents preceding the ex- 
 periment. He does not know, for instance, whether or 
 not he has given his consent to the experiment. At this 
 place it is necessary to remark that the experiment re- 
 quires great caution. The compression of the arteries 
 has to be performed very slowly. Immediately after 
 unconsciousness has ensued, the compression of the ar- 
 teries must cease, and this very gradually too. With 
 this precaution the experiment is not dangerous. 
 
 Another peculiar disturbance of memory consists in 
 deception of memory. Even sane people have some- 
 times a feeling as though they had been before in a given 
 
6S PSYCHE 
 
 situation, although this has never been the case. This 
 feeHng is transient. But there are patients in whom 
 such feehngs are rather permanent. They maintain, 
 without any affectation or boastfulness, to have known 
 or seen things that are shown to them for the first time 
 in their Hfe. Confounding of persons is based on such 
 deceptions of memory. The patients beHeve to know a 
 person whom they meet for the first time, or to recognize 
 in him an old acquaintance. Things belonging to others 
 are appropriated by such patients and claimed as their 
 own, and in this way they may come into conflict with 
 the Penal Code (pp. 89, 255). 
 
 Chapter XXXV. 
 COMPULSORY IDEAS. 
 
 Certain ideas have been designated as compulsory 
 C'Zwangsideen"). The person harboring these ideas 
 is, somehow or other, under compulsion to have them 
 constantly in his consciousness and cannot rid himself 
 of them. Compulsory ideas are met with not only in 
 patients, but also in persons who are sane and even in- 
 telligent and equal to their vocation in life. 
 
 It has been said every idea that intrudes upon the 
 consciousness of a person and persists against his will is 
 a compulsory idea. This definition is too narrow; for 
 there are ideas which are intruding upon the conscious- 
 ness of a person and persisting against his will and yet 
 cannot justly be called compulsory. A person may com- 
 mit a wrong and be constantly haunted by the idea of 
 his improper act, and yet the term compulsory idea is 
 
GENERAL PATHOLOGY 69 
 
 1 
 not applicable to such an instance. We speak here rather 
 of the voice of conscience. When one is expecting an 
 event capable of causing him sorrow or joy, the idea of 
 it intrudes upon his mind and persists against his will. 
 A student often has to think of the imminent examina- 
 tion in the midst of his pleasures, and yet we do not say 
 he is suffering from a compulsory idea. 
 
 To arrive at the proper conception of compulsory 
 or imperative ideas, it is advisable to consider a few ex- 
 amples of ideas which may unquestionably be called 
 compulsory. A patient complained that the number 13 
 was always present in his mind. He knows that a certain 
 significance is attributed to this number, but he does not 
 share this superstition. Another patient was grieved 
 about having to think of certain blasphemous words 
 whenever he took a prayer book into his hands. In spite 
 of his endeavors he does not succeed to disconnect in his 
 thoughts obscene things from holy ones. On the con- 
 trary, when he does not resist the course of his thoughts, 
 he feels more relieved. Again another patient was an- 
 noyed that whenever he beheld a woman he could not 
 dissociate from her the idea of her being pregnant. 
 
 The common feature in all these instances is that 
 the patients are perfectly convinced of the insignificance 
 and absurdity of the idea that occupies their mind. In 
 other instances, however, the subject of the idea is of 
 great importance. A woman, mother of one child, was 
 constantly haunted by the thought that the child might 
 fall out of the window during her absence. In this alone 
 there is nothing strange inasmuch as any tender mother's 
 mind may very well be invaded by such a thought. But 
 the pathological feature is that she was compelled to 
 imagine the child had fallen down and was lying on the 
 
70 PSYCHE 
 
 ground with crushed Hmbs. She fancied that when she 
 would be in the room with the child at the window, she 
 might push it off from the sill to see whether the actual 
 scene of the child falling down and being crushed cor- 
 responded to the horrible picture of her imagination. 
 She was positively afraid to be alone in the room with 
 the child. 
 
 Another form of compulsory idea is the tendency 
 to ponder over problems which do not have the slightest 
 value C'Grubelsuchf'). The patients constantly analyze 
 nonsensical questions, for instance, why two times two 
 are four and no other number, or why the world has 
 been created in six days and not in five. The patients 
 are aware of the ridiculousness of these problems. 
 
 To the compulsory ideas belongs the habit of doubt- 
 ing — folic du doute. At night before going to bed the 
 patient shuts the gate of the house. When he has laid 
 himself to sleep, he gets the idea that he did not close 
 the gate properly. It worries him so long that he feels 
 compelled to get up and convince himself that the gate 
 is closed. When he is in bed again, the same idea begins 
 to disturb him anew and causes him to get up. This may 
 be repeated several times. Something similar occurs in 
 writing letters, counting money, extinguishing lights, and 
 so on. One writes a few letters and puts them in their 
 respective envelopes. Thereupon the idea begins to 
 trouble him that he has mixed up the letters and compels 
 him to tear open the envelopes. This act he has to repeat 
 several times. Another one cannot satisfy himself that 
 he has counted his money correctly and has to count it 
 over and over again. 
 
 Among the compulsory ideas are to be counted the 
 various phobias. Some patients suffer from the fear of 
 
GENERAL PATHOLOGY 71 
 
 contact — delire du contact. They scrupulously avoid 
 touching many things for fear of taking in some germ 
 of disease. Other patients have casually read that people 
 had become victims of rabies without knowing that they 
 had been bitten by a dog. From that moment the idea 
 worries them that they also may have been bitten by a 
 mad dog without knowing it. Some patients are in con- 
 stant fear of their clothes becoming dusty or of being 
 soiled in some other way — mysophohia. Patients affected 
 with the so-called agoraphobia are unable to pass a public 
 square or a street, or to approach a gathering of peo- 
 ple (p. 39). Astraphohia is the exaggerated fear of 
 thunder and lightning. The patients are seized with 
 apprehensive excitement even at the approach of thun- 
 derstorms and are sometimes so sensitive that they can 
 predict them long before they appear, the same as rheu- 
 matic patients foretell weather-changes. Patients suffer- 
 ing from claustrophobia are afraid to stay in closed 
 rooms. Other phobias refer to the activities of the in- 
 ternal organs. Thus some patients are in constant fear 
 that their heart may stop, or their lungs discontinue to 
 breathe. 
 
 These are all examples of real compulsory or im- 
 perative ideas. It is true, they persist in the conscious- 
 ness of the patient against his will. But this is not 
 essential. What is more important is that he cannot rid 
 himself of them notwithstanding his firm conviction of 
 their absurdity and insignificance. A patient laboring 
 under agoraphobia knows very well that no disaster is 
 likely to befall him in crossing a street. 
 
 To obtain a satisfactory definition of compulsory 
 idea the question must be answered what enables a 
 healthy person to retain certain ideas and to abandon 
 
72 PSYCHE 
 
 others forthwith, for instance, what makes him give up 
 thinking why two times two are four and no other 
 number. He succeeds herein first by the conviction of 
 the utter insignificance of the problem. But since pa- 
 tients also have this conviction, some other factor must 
 play an important part. This factor is found when 
 intelligent patients are questioned. They report that 
 they are well aware of the absolute insignificance and 
 even of the ridiculousness of the idea they constantly 
 have to keep in mind, but that nevertheless they cannot 
 get rid of a certain feeling as though the thing is im- 
 portant after all. To this feeling they have to yield 
 contrary to their conviction. Now, in the healthy per- 
 son with the knowledge that a problem is insignificant 
 and void is connected a corresponding feeling that the 
 problem is to no purpose. It is a peculiar affective tone. 
 It is owing to this feeling that he is not compelled to 
 think over the useless problem and is able to dissociate 
 it from the train of his thoughts. In the diseased indi- 
 vidual, however, the conviction of the insignificance of a 
 thing either lacks the normal affective tone or is accom- 
 panied by an abnormal feeling. All these preceding con- 
 siderations lead us to the following definition of com- 
 pulsory idea. // with a certain idea an abnormal affec- 
 tive tone is associated, and, due to this morbid feeling, 
 the idea is retained in consciousness against the will not- 
 withstanding complete conviction of the insignificance 
 of the subject, this idea is a compulsory, imperative idea. 
 Compulsory ideas are met with during convalescence 
 from psychoses. But also persons who have never had 
 a psychosis may be subject to them. As a rule, those 
 affected are people with a family history of insanity. 
 
GENERAL PATHOLOGY 73 
 
 Fatigue may also be regarded as an etiological factor, as 
 in psychasthenics. 
 
 Some patients become incapacitated for useful work 
 through their compulsory ideas. Other patients have 
 even to be committed to an insane asylum on account of 
 them. For such ideas sometimes increase to impulses, 
 and the latter may lead to compulsory actions which ren- 
 der the patient dangerous to himself and his neighbors 
 (Chapter 42, p. 86). 
 
 Chapter XXXVI. 
 
 MORBID ALTERATION OF THE ACTIVITY OF THE 
 UNDERSTANDING. 
 
 In abnormal conditions of the memory, which fur- 
 nishes the elements for the activity of the understand- 
 ing (p. 21), the latter is also morbidly affected. As 
 with memory so also with understanding increased and 
 diminished capacity may be distinguished. 
 
 When the ideational process is facilitated, there is 
 more ready material for the activity of the understand- 
 ing. In maniacal excitement of moderate degree, there- 
 fore, the capacity of understanding is enhanced (Ch. 
 8, pp. 19-20; pp. 36, 61, 62). It is generally known that 
 moderate excitement sometimes improves the intellec- 
 tual faculties. Some people seek a little excitement when 
 they have to perform a difficult mental task; they drink 
 some wine or strong coffee or smoke a little. These 
 stimulants produce a slight excitement which renders 
 thinking more easy by facilitating the association. Pa- 
 tients in maniacal excitement are quicker at repartee, 
 more wittv, and draw conclusions from their obser- 
 
74 PSYCHE 
 
 vations with more ease than usually. But when the 
 maniacal excitement is great, the understanding is im- 
 paired, owing to '^flight of ideas" (pp. 36, 42). 
 
 Sometimes increased capacity of understanding is 
 merely apparent, as in the hypermnesia of the idiots 
 (pp. 62-63). These patients may create the impression 
 of being highly intelligent simply by virtue of their faith- 
 ful memory which enables them to learn quickly and to 
 appropriate ideas and judgments of others more readily 
 than is normally the case. 
 
 Far more frequent than the increased is the dimin- 
 ished capacity of understanding. It is observed in the 
 transitory retardation of the ideational process in melan- 
 cholia. The understanding of melancholic patients is 
 secondarily impaired, being influenced by the difficulty 
 of association. It is laborious for the melancholies to 
 combine sensations and memory images. When the 
 melancholic depression has ceased, the understanding 
 gradually improves (pp. 19-20, 35, 64). 
 
 In primary insanity, paranoia, an impairment of 
 understanding, occurs which may be called ''want of 
 critique." The patients are unable to gauge, so to say, 
 their observations, to pay attention to the quantitative 
 elements of the understanding. A few examples will 
 suffice. A patient maintained that, owing to his intimate 
 relations to the Bavarian Royal House, he had excellent 
 prospects for the future. Called upon to prove his asser- 
 tion, he argued as follows : His foot stool had the colors 
 blue and white; the colors of the Bavarian Royal house 
 were also blue and white, therefore he belonged to the 
 Royal house. The facts are unquestionably correct, but 
 the conclusion drawn from them is anything but rational. 
 Another patient said that he would become governor of 
 
GENERAL PATHOLOGY 75 
 
 the state, and the only reason he gave for this statement 
 was that his birth fell on a certain date. This "want of 
 critique" is never missing in paranoiacs. They interpret 
 the most casual circumstances to their advantage or dis- 
 advantage. This impairment of understanding may 
 be transitory. Should the acute mental malady pass 
 away or come to a standstill, the power of understand- 
 ing may become normal again. 
 
 In some cases where the capacity of understand- 
 ing appears to be reduced we are dealing merely with 
 delusions. It is necessary to bear this point in mind 
 since real impairment of understanding involves more 
 or less an unfavorable prognosis. When a patient 
 utters an obvious absurdity, for instance, when a rich 
 patient complains about dire poverty, we must not as- 
 sume at once that his power of understanding has been 
 really reduced. Melancholic patients often express sim- 
 ilar nonsensical assertions which are nothing else but de- 
 lusions, and do not signify an impairment of under- 
 standing. That in such instances the capacity of under- 
 standing has not suffered, is proved by the fact that 
 the patients are again in full possession of their intelli- 
 gence when the delusions cease with the discontinuance 
 of their own causative factors, morbid mood and hallu- 
 cinations (Ch. 25, pp. 53-54). 
 
 The capacity of understanding is permanently low- 
 ered in idiocy, in secondary dementia, and in general 
 paresis. The greatest diminution of the intellectual 
 faculties is met with in these conditions. Persons mag- 
 nificently gifted intellectually may become so stupid that 
 they do not recognize their nearest relatives, are unable 
 to tell their name or their age, and so on. 
 
 In forensic respect laymen ascribe too much impor- 
 
j(> PSYCHE 
 
 tance to the faculty of understanding. They consider a 
 crime punishable, if the criminal has acted consciously 
 and intelligently. Now, insane criminals report that in 
 committing a wrong act they were in full possession of 
 their consciousness and understood very well the criminal 
 bearing of their action. Yet they performed it, induced 
 by a delusion, for instance, by the delusion of being per- 
 secuted. Society ought not to inflict punishment in such 
 cases. For it ought not to inquire whether or not a 
 criminal has acted intelligently, but whether he has acted 
 in a state of unconsciousness or such other derangement 
 of the mental faculties in which freedom of the will 
 could be excluded. 
 
SECTION III. 
 
 PATHOLOGY OF THE ACTIVITY OF 
 THE WILL 
 
 Chapter XXXVIL 
 
 INCREASE AND DECREASE OF THE FREQUENCY 
 OF VOLITIONAL MANIFESTATIONS. 
 
 The activity of the will has a positive and a nega- 
 tive side. For will is the capability of reenforcing 
 motor images to such an extent that movements ensue, 
 and on the other hand of weakening motor images so 
 that movements for which an incentive is present are 
 suppressed. 
 
 Morbid alteration of the activity of the will is a 
 very frequent, diagnostically important symptom. It is 
 met with in mild and in grave forms of mental disease. 
 A common symptom of psychasthenia is the want of 
 choice or initiative, aboulia, paralysis of the will. The 
 patients are unable to accomplish the plainest actions, 
 they vacillate and hesitate and cannot come to a decision. 
 
 In graver mental diseases disturbance of the activity 
 of the will becomes most conspicuous through unusual 
 frequency of the volitional acts. It may be abnormally 
 increased or abnormally diminished, the patient being 
 compelled to act according to his condition. While the 
 sane person has the choice of performing few volitional 
 acts or many, the patient in whom the frequency of voli- 
 tional manifestations is abnormally increased cannot re- 
 
78 PSYCHE 
 
 duce it, and conversely, when it is abnormally diminished, 
 the patient is unable to carry out many movements. 
 
 Increased volitional activity is a salient symptom of 
 maniacal excitement. The movements of the patients 
 are rapid. They speak quickly. In conversation one 
 hardly succeeds to make them stick to one subject. They 
 are extremely restless. They cannot sit quietly for a 
 moment, now they do this, now that. When they are iso- 
 lated, they tug at their clothes, tear and tatter them, pluck 
 and twist their hair, and perform all kinds of manipula- 
 tions. The patients cannot behave differently; we may 
 say they are under an irresistible impulse for movement. 
 
 The patient with diminished frequency of volitional 
 manifestations, hypoboulia, sits quietly and hardly stirs. 
 In extreme cases the patients are unable to take nourish- 
 ment or to swallow food introduced into their mouths, 
 and even normal reflex movements may remain in abey- 
 ance. Such a reduction of the volitional processes is 
 seen in stupor (Ch. 72, p. 159). A more moderate sup- 
 pression of the activity of the will belongs to the symp- 
 toms of melancholia. The patients remain sitting on 
 one spot for hours. They make no effort to go to bed 
 at night, to undress themselves, or to get up in the morn- 
 ing. They stay in bed for days and weeks, not leaving 
 it even after having soiled it. They are extremely re- 
 ticent. A conversation can be carried on with them only 
 with great difficulty, at most they answer yes or no to 
 some questions. An exact description of what is ailing 
 them cannot be obtained from them. They speak with a 
 low voice and slowly, they walk hesitatingly and halt 
 frequently. This diminution of the activity of the will 
 is transitory, ceasing with the disapperance of the melan- 
 cholic depression. 
 
GENERAL PATHOLOGY 79 
 
 The frequency of the volitional manifestations is 
 permanently reduced in some cases of secondary de- 
 mentia. Some demented patients are so apathetic that 
 they remain motionless on one spot for so long a time 
 that their extremities become swollen. They may be 
 unable to eat and drink, to dress and undress themselves, 
 etc. This lethargic condition stays with such patients 
 throughout their lives. 
 
 Chapter XXXVIIL 
 TICS, STEREOTYPY. 
 
 Among the disturbances of volition are to be in- 
 cluded certain abnormal motor phenomena not infre- 
 quently observed in mental diseases. 
 
 The tics are curious gestures and motions, such as 
 twitching of muscle groups, grimacing, licking the palate, 
 clucking with the tongue, snuffling, throwing head and 
 limbs in various positions, etc. These sudden incoordin- 
 ate movements are sometimes responses to external 
 stimuli. Usually, however, they represent the rigid re- 
 mains of habitual actions and movements, ensuing auto- 
 matically or not controlled by the will (Kraepelin). 
 
 Similar to the tics are the stereotyped movements. 
 Normally every impulse ceases when its aim has been 
 reached. Another impulse enters the field of conscious- 
 ness only to be supplanted, after attainment of its end, 
 by a new impulse. Thus complex actions are accom- 
 plished by one impulse replacing its predecessor when 
 the latter 's part of the action has been achieved. This 
 normal harmony of the common impulses may be dis- 
 turbed. Stereotypy is the morbid persistence of a motor 
 
8o PSYCHE 
 
 impulse causing the patient to persevere in certain atti- 
 tudes for a long time or to repeat certain movements 
 over and over again. Stereotypy of attitude is desig- 
 nated as akinetic, that of movement as kinetic. 
 
 Patients showing akinetic stereotypy keep up cer- 
 tain postures of body and Hmbs for any length of time, 
 even though they may be extremely uncomfortable. 
 Some patients kneel for hours and days on a hard floor, 
 others lie in bed with extended head and curled limbs, 
 the body being so rigid that it can be lifted by one limb. 
 In stereotyped attitudes of the facial muscles there is a 
 continued distortion of the features. The face assumes 
 a mask-like appearance, the eyes are staring without the 
 slightest movement of the lids, or else the lids are tightly 
 closed, the lips are protruded forming a snout (''snouting 
 cramp"), etc. 
 
 In kinetic stereotypy the patients perform certain 
 acts innumerable times, such as rocking, hopping, jump- 
 ing, rapping rhythmically, pacing up and down the room 
 in the same line, etc. 
 
 Frequently the patients exhibit with their stereo- 
 typed movements a certain affectation — inannerism. 
 They walk in a solemn attitude, describing circles or 
 other lines. Mannerism is manifested especially in 
 stereotypy of speech. The patients use stilted language 
 and speak in an affected manner, e. g., lisp, speak in a 
 falsetto voice, weep after a certain melody, etc. 
 
 Verbigeration is the c(^tant repetition of senseless 
 syllables, words, and phrases. It occurs not only in oral, 
 but also in written language. In the writing of the pa- 
 tient a page may be found containing nothing else but 
 the same word or phrase written over and over again. 
 
GENERAL PATHOLOGY 8i 
 
 Chapter XXXIX. 
 INTERFERENCE, DERAILMENT OF THE WILL. 
 
 In stereotypy many actions never lead to a goal 
 because of the persistence of one impulse which pre- 
 cludes other impulses pertaining to the actions. There 
 is, however, another disturbance of volition in which the 
 goal is finally reached, but by a long roundabout way. 
 Fortuitous impulses arise, interfering with those on 
 which the intended act depends, and delay its accom- 
 plishment. The latter comes about after the interpolation 
 of superfluous operations which appear as embellish- 
 ments of the intended act (Kraepelin). The patient puts 
 his garment on inside out, walks with short steps, swings 
 the chair in the air before sitting down, crosses his arms 
 when shaking hands, makes various manipulations with 
 the spoon in eating, drinks water with little sips, etc. 
 
 From this interference of fortuitous impulses with 
 the main impulses there is a gradual transition to that 
 disturbance of the will in which the goal of the intended 
 act is not reached at all because the incidental impulses 
 divert the patient in a different direction — derailment of 
 the ivill. He stands up to walk into another room, but 
 trips along, dances about, and sits down again. He 
 starts to drink a glass of water, but turns it upside down 
 and puts it on the table. His countenance assumes an 
 attitude of weeping and tears fill his eyes, and then his 
 face becomes suffused wi#|fsmiles — paramimia. 
 
82 PSYCHE 
 
 Chapter XL. 
 HYPERSUQQESTIBILITY, NEGATIVISM. 
 
 It may be regarded as a disturbance of the negative 
 side of the will (p. "jy) when actions follow too readily 
 upon inadequate stimuli. Such patients lack the will 
 power to disregard incentives too trivial to call forth 
 responses in normal persons. They are possessed by a 
 hyper suggestibility which causes them to respond to any 
 accidental influence. The perception of a certain move- 
 ment is for them a sufficient stimulus to make this move- 
 ment. They wrinkle the forehead, whistle, jump, when 
 they see others do so — automatism of imitation, echo- 
 praxia. Sometimes they repeat what one says in their 
 presence, or interpolate frequently in their talk irrelevant 
 words and phrases which they have accidentally heard — 
 echolalia. Hypersuggestibility is a characteristic feature 
 of hypnotism. A command from the hypnotizer is suffi- 
 cient incitement for his subject to perform all kinds of 
 senseless actions — automatism of command. 
 
 Hypersuggestibility is observed in various mental 
 disorders. In catalepsy the will power is so weak that 
 the limbs of the patient can be put in any position and, 
 in spite of great discomfort, remain in that position un- 
 til one changes it, or until they drop owing to complete 
 exhaustion of their muscles. The peculiar rigidity of 
 the muscles in these conditions is called fiexihilitas cerea. 
 
 The disturbance of volition, called negativism, and 
 in its manifestations almost the contrary of hypersug- 
 gestibility, consists in an exaggerated inaccessibility to 
 any external influence. The patient ofl^ers resistance to 
 the requirements of environment and circumstances, re- 
 fuses to fulfill the most reasonable demands, and even 
 
GENERAL PATHOLOGY 83 
 
 does just the opposite of what he is requested to do. He 
 does not respond to a greeting and recoils when ap- 
 proached even in the most friendly way. He withdraws 
 his arm when the hand is offered him in greeting, presses 
 his teeth together when asked to show his tongue. To- 
 wards all questions he remains mute — mutism, or brings 
 forward entirely irrelevant utterances — paralogia, ''Vor- 
 beiredcnf He does not heed even his physical needs, 
 refusing to eat or drink, or to evacuate bladder and 
 rectum, especially when exhorted to do so. 
 
 Chapter XLL 
 MORBID ALTERATION OF THE ENERGY. 
 
 Energy is displayed in two ways, in the application 
 of great muscular power while acting, and in persistent 
 and purposeful action. For the sake of brevity the first 
 form of energy may be called energy of force, the second 
 energy of persistence. Both forms of energy may show 
 morbid alteration, most frequently, however, only one is 
 changed. Some patients manifest an increase of one 
 form and a decrease of the other. 
 
 Increase of the energy of force is met with in 
 maniacal excitement. The maniacs speak loudly, as 
 though their listeners were hard of hearing. When their 
 attention is called to their loud speech, they lower their 
 voice for a while, but soon resume their former powerful 
 tone. Their step is firm, their grasp forceful. In short, 
 everywhere they apply considerably more power and 
 strength than is required for the attainment of the pur- 
 pose. Their performances are sometimes incredible. 
 
S4 PSYCHE 
 
 They bend iron bars, rend strait- jackets, break massive 
 furniture. Nothing seems to be too firm for them. 
 Some have maintained that the muscular power of 
 maniacs is actually increased. But this is not the case. 
 They merely apply that amount of force which the sane 
 person would use only in the highest distress and danger. 
 The maniacs perform such astonishing deeds because 
 they are inconsiderate of their health. By instinct the 
 sane person avoids applying more power than^ is just 
 necessary to accomplish a certain end. He thus reserves 
 his strength and wards off the harm which the abuse of 
 muscular power entails. Maniacs lack this fine instinct 
 and go, therefore, far beyond the required measure of 
 power in using their muscles. 
 
 Paretics in maniacal excitement behave in a similar 
 manner, but do not possess the same dexterity and elas- 
 ticity as other maniacs. Their movements do not lack 
 coarse muscular power, but fail to show skil fulness and 
 finer coordination. 
 
 The abuse of muscular power shows itself also in 
 unusually long duration of an action. In this respect 
 astonishing examples of great energy are observed in 
 maniacs. They walk up and down the room for days 
 and weeks, they talk incessantly in a very loud tone of 
 voice for weeks and even months. 
 
 Diminution of the energy of force is met with in 
 melancholic patients. Their grasp is weak, they speak 
 with a low, feeble voice, they walk slowly and with in- 
 firm step. In an emotional attack of fear, however, they 
 may display great muscular strength (pp. 33, 34). Mod- 
 erate reduction of the energy of force is also seen in de- 
 mented patients. The maximum lowering of this form 
 of energy is observed in stupor. All that stuporous 
 
GENERAL PATHOLOGY 85 
 
 patients can still accomplish by muscular power is to 
 stand quietly as if rooted to the spot, motionless for 
 hours. 
 
 As to purposeful and persistent action, the energy 
 is increased in paranoiacs. With greatest consideration 
 and perseverance they pursue a certain design. Induced 
 by delusions, for instance by the delusion that somebody 
 wants to poison them, they steadfastly decline to take 
 nourishment. They may be so consistent in their refusal 
 of food that they would actually die of starvation if 
 artificial feeding were not resorted to. Paranoiacs influ- 
 enced by delusions perform actions which sane persons 
 would never be capable of. In this category belong hor- 
 rible self-mutilations or self -crucifixion. Great persistence 
 is shown by paranoiacs in carrying out plans of flights. 
 With finesse they manage to procure a piece of iron, 
 make a sort of file out of it, and saw through the window 
 bars. Day after day they file a little at a bar until it 
 finally yields. Increased energy is also seen in the plans 
 which patients contrive against the lives of those who 
 restrict their freedom, or in the manner in which they 
 accomplish self-destruction. If all instruments to com- 
 mit suicide have been removed, they kill themselves by 
 running head forward against a wall, a feat for which 
 incredible energy is required. Some patients also show 
 great energy in enduring hardships, as extreme cold or 
 heat. 
 
 Increased energy of persistence similar to that of 
 paranoiacs is sometimes observed in idiots. 
 
 Enhancement of the energy of persistence is much 
 more frequent in psychoses than increased energy of 
 force. The latter sometimes exists without the former. 
 This is especially the case in maniacal excitement. The 
 
86 PSYCHE 
 
 stronger the agitation of the patient, the less is he able 
 to pursue a purpose. Owing to "flight of ideas" the 
 maniac is unable to carry out an intention completely, 
 being easily diverted in another direction. To this qual- 
 ity is due the " tractahllity" of the maniacs. By taking 
 advantage of it a raging maniac may be easily subdued, 
 while otherwise the help of several attendants would be 
 required to manage him. Physicians would do well to 
 bear this point in mind in the handling of maniacal 
 patients. 
 
 The energy of persistence is diminished in secondary 
 dementia. The patients cannot accomplish anything they 
 desire,, are unable to evade a danger when brought face 
 to face with it. 
 
 In patients mentally deficient since birth or early 
 childhood increase as well as decrease of the energy of 
 persistence is met with. The plans of idiots vary from 
 day to day, a slight allurement suffices to divert them 
 from their intention. It has been mentioned above that 
 at times they may resemble paranoiacs in exhibiting per- 
 severance. 
 
 Chapter XLII. 
 
 COMPULSORY ACTIONS. 
 
 Compulsory or imperative actions originate from 
 compulsory or imperative ideas (Ch. 35, p. 68) which, 
 increasing considerably in intensity, are converted into 
 imperative impulses. For instance, a patient sees a razor 
 and the idea of cutting his throat with it begins to tor- 
 ment him. This is an imperative idea. Now there may 
 supervene the strong desire to grasp the razor and inflict 
 the injury. This is an imperative impulse. If the pa- 
 
GENERAL PATHOLOGY ^7 
 
 tient accomplishes his morbid desire, he performs a com- 
 pulsory action. 
 
 Patients suffering from compulsory ideas feel that 
 they would be unable to resist executing those acts to 
 which they are instigated by the ideas. When, therefore, 
 they are laboring under a compulsory idea pernicious to 
 themselves or to others, they hide every dangerous in- 
 strument and avoid every occasion that would render 
 possible the execution of the imperative action. 
 
 Compulsory ideas and actions play an important 
 part in forensic matters, because they frequently include 
 dangers not only to the patients, but also to others. To 
 be exonerated from a penal act a malingerer may allege 
 that he has been under the influence of a compulsory 
 idea while committing the act. But such deception can 
 usually be detected without mucli difliculty. For the 
 actions of malingerers turn out almost always to their 
 own advantage, while true compulsory actions are usually 
 to no purpose. When a mother having killed her child 
 maintains to have been under the influence of a compul- 
 sory idea, there may be the possibility of her seeking 
 gain, as an inheritance, by the death of the child. But 
 closer investigation will make the matter clear. The 
 medical expert, in order to impress the court and obtain 
 recognition for his testimony, must demonstrate how 
 compulsory actions originate and how they are executed. 
 A mother being haunted by an idea detrimental to her 
 child reveals it to others. She implores them not to leave 
 her alone with the child lest she do it harm. If an utter- 
 ance of the mother to this eft'ect has been established, 
 the judge will become convinced that he is dealing with 
 a true imperative action and will not deein the defendant 
 fully responsible. 
 
88 PSYCHE 
 
 Chapter XLIII. 
 MORBID IMPULSES. 
 
 The natural impulses (Ch. ii, p. 26) may be mor- 
 bidly increased or decreased. Thus maniacs show some- 
 times increased sexual desire or ravenous appetite. Mor- 
 bid decrease of a natural impulse expresses itself in a 
 most striking manner through refusal of food, the patient 
 acting against the instinct of self-preservation which is 
 the strongest of all natural impulses. 
 
 Some writers have advanced the opinion that there 
 is an impulse for murder — phonomania'^ , or for theft — 
 kleptomania, etc., in individuals otherwise entirely nor- 
 mal. But this view is erroneous. For whenever indi- 
 viduals display remarkable tendencies to theft or murder 
 
 * There is, as far as the writer has been able to ascertain, no 
 medico-legal term for "impulse for murder," derived from purely 
 Greek roots in a manner corresponding exactly with the Greek 
 designations of other morbid propensities, such as morbid pro- 
 pensity for theft, kleptomania; for incendiarism, pyromania; morbid 
 sexual desire (in women), nymphomayiia, etc. These derivations 
 furnish directly short, convenient terms denoting the person affected 
 with those propensities, as kleptomaniac, one afflicted with the pro- 
 pensity for theft, etc. Homicidal mania, as a medico-legal term, 
 with its half Latin, half Greek basis, sounds rather barbaric to a 
 philologically trained ear, and is inconvenient because, unlike the 
 terms for other morbid propensities, it consists of two words. The 
 writer has, therefore, coined the word phonomania, from the Greek 
 6 povog, the murder, homicide. This gives at once the convenient 
 expression phonomaniac, one bent on murder. 
 
 No less an authority on medical terminology derived from 
 the Greek than Dr. Achilles Rose has approved of the coinage of the 
 word, and has refuted the writer's own objection that phonomania 
 (<l>ovofiavta) written with Latin characters, may also mean "mania 
 for voice" {^Mvofiafia, from r) (puivt), the voice), with the remark 
 that "a confounding with (piovof-tatia is excluded because something 
 like this does not exist." 
 
GENERAL PATHOLOGY 89 
 
 or other outrages, we can, on closer investigation, make 
 out delusions underlying such impulses. An impulse to 
 steal, for instance, is observed in paretics; they regard 
 everything as their own and try to appropriate it (p. 255 ). 
 The assumption of isolated impulses is to be emphatic- 
 ally rejected. Otherwise the old doctrine of monomanias, 
 fortunately overthrown and abandoned, would be re- 
 established. 
 
 Perversities of the natural impulses are quite fre- 
 quent. Sexual perversities are the most common and 
 best known. Other perversities are less known. Patients 
 lacking the feeling of disgust may satisfy their alimen- 
 tive impulse in a perverse manner (Ch. 19, p. 38). 
 
SECTION IV. 
 PATHOLOGY OF CONSCIOUSNESS. 
 
 Chapter XLIV. 
 
 DISTURBANCE OF SLEEP, SOMNAMBULISM, 
 HYPNOTISM. 
 
 Sleep occurs periodically and is characterized by 
 great reduction of consciousness. Normally falling 
 asleep and awaking require only a comparatively short 
 time, and after awaking full consciousness returns read- 
 ily and quickly. These features of sleep may be altered 
 in pathological conditions. There are patients who gain 
 their sleep slowly and with difficulty. Other patients, 
 on the contrary, make all efforts to remain awake and 
 yet cannot help falling asleep even while standing or 
 walking or on horseback. Consciousness is reduced in 
 some patients much less than is normally the case, and 
 after awaking these patients do not regain full conscious- 
 ness for a long time. In this semiconscious state they 
 perform complicated actions — automatism. Cases are 
 reported where coachmen have arisen from bed in the 
 dead of night, have led the horses out of the stable, have 
 harnessed them, and have driven to distant places, all this 
 in a semiconscious state. Such conditions occur in indi- 
 viduals who are toiling all day long. 
 
 A sort of half-sleep is the so-called somnambulism, 
 
GENERAL PATHOLOGY 91 
 
 sleep-walking. At night the patients arise in their sleep 
 and, without regaining full consciousness, accomplish 
 acts which are very remarkable. They may move about 
 unfalteringly at a giddy height on a narrow board. Lay- 
 men see in such accomplishments something mysterious. 
 But there is no mystery therein. The sleep-walkers can 
 accomplish such feats because they are not aware of 
 their danger and are, therefore, not seized with dizziness 
 as would a waking person under similar circumstances. 
 Indeed, there is nothing out of the ordinary in walking 
 over a narrow board from one roof of a house to that 
 of another. No broader path is necessary for a similar 
 walk on the ground. The dizziness produced by the 
 great height makes the passage over the narrow board 
 well-nigh impossible to a person awake. When the sleep- 
 walker is awakened, he is put into a critical position. 
 For he becomes conscious of his extraordinary and pre- 
 carious condition and is, therefore, liable to meet with a 
 fatal accident. 
 
 Related to somnambulism is hypnotism, which rep- 
 resents a sleep produced by suggestion, either by the 
 suggestion of others or by autosuggestion. Its most re- 
 markable feature is the hypersuggestibility of the hypno- 
 tized person, enabling the hypnotizer to keep up a spiri- 
 tual communication with his subject. Complicated acts 
 may be performed by the hypnotized person in this state 
 of unconsciousness at the command of the hypnotizer — 
 automatism of command. 
 
92 PSYCHE . 
 
 Chapter XLV. 
 
 DOUBLE CONSCIOUSNESS, STATES OF CLOUDED 
 CONSCIOUSNESS IN EPILEPSY AND HYSTERIA. 
 
 The existence of a so-called double consciousness 
 has been claimed by some writers. According to their 
 assertion there are individuals who periodically fall into 
 a state of impaired or altered consciousness during 
 which they perform certain actions. After awaking from 
 such a state they do not remember anything that has 
 transpired during the period. This alone would not be 
 very strange, for something similar occurs also in epilep- 
 tics. But what is remarkable is that events which have 
 taken place during these spells can be recollected only in 
 subsequent spells, but not in the intervals. The same 
 holds good conversely of the intervals. The individual 
 is possessed, as it were, of two consciousnesses. Each 
 of them exists at a different time and has a memory for 
 itself, but not for its fellow, so that the individual is able 
 to recollect events which have occurred in the state of 
 one consciousness, only in a repeated state of the same 
 consciousness. But all the reports of this nature which 
 have been adduced to confirm the theory, have not been 
 convincing. 
 
 In epilepsy states of clouded consciousness occur 
 which have been called the psychic equivalents of the 
 epileptic attacks. They have been explained in the fol- 
 lowing way: Epileptics are sometimes subject to spells 
 in which the motor sphere k> not affected and only their 
 consciousness undergoes a change, while the ordinary, 
 completely developed attacks consist in both convulsions 
 and loss of consciousness (pp. 243-244). In these semi- 
 conscious states the epileptics may commit dangerous 
 
GENERAL PATHOLOGY 93 
 
 acts. The psychic equivalents are met with especially 
 in traumatic epilepsy coming on after the age of 20 
 years. Although consciousness is not entirely lost in 
 the psychic equivalents, the patients do not recognize 
 their surroundings and have afterwards a gap of mem- 
 ory for the whole time the spell has lasted. 
 
 Similarly hysterical patients are subject to spells of 
 disturbed consciousness. 
 
 Chapter XLVL 
 
 DISTURBANCE OF CONSCIOUSNESS IN GENERAL 
 PARESIS AND IN DELIRIA. 
 
 Disturbance of consciousness is quite frequent in 
 the course of general paresis. The patients are seized 
 with attacks either of apoplectiform or of epileptiform 
 character. In the first case they suddenly fall to the 
 ground and lose consciousness, creating the impression 
 that a cerebral hemorrhage has taken place. But this is 
 usually not the case. For, in the first place, the attack 
 is evanescent, the patients usually recovering within a 
 very short time. Secondly, in case of death a hem- 
 orrhage cannot be demonstrated in the brain at the 
 autopsy. The epileptiform attacks of the paretics are 
 characterized by loss of consciousness associated with 
 convulsions in a manner similar to the attacks of the 
 epileptics. 
 
 Consciousness is disturbed in delirious states. 
 These are generally of toxic origin, as the deliria in the 
 course of the acute infectious diseases, in which they 
 are caused by toxines, and the deliria of drug poison- 
 
94 PSYCHE 
 
 ing, as in morphine, atropine, cocaine poisoning and in 
 chronic alcoholism. 
 
 Chapter XLVIL 
 DISTURBANCE OF SELF=CONSCIOUSNESS. 
 
 Disturbance of self -consciousness is frequently met 
 with in many psychoses. Self -consciousness has been 
 defined as the individual's judgment about his own per- 
 sonality whereby he recognizes his relation to the ex- 
 ternal world (p. 28). When, therefore, insane patients, 
 due to a morbid affective state or to delusions, overesti- 
 mate or underestimate themselves, as is the case with 
 maniacs, melancholies, paranoiacs, etc., they are affected 
 with impairment of self-consciousness. 
 
 When patients fail to recognize their relation to 
 the external world, especially when they lack the proper 
 comprehension of time and space, we speak of disorien- 
 tation. Disorientation may be due to defects of memory 
 and judgment, to hallucinations, and to delusions. 
 
SECTION V. 
 SOMATIC DISTURBANCES IN THE INSANE. 
 
 Remark. In all exactness mental disorders are somatic dis- 
 turbances. For ultimately they are due to some pathological 
 process going on in the brain, an organ of the body. But in a more 
 restricted sense somatic disturbances are taken to be those physical 
 anomalies which have no direct relation to the psychical functions 
 of the brain, and yet are frequently met with in patients suffering 
 from mental diseases. 
 
 Chapter XLVIII. 
 
 DISTURBANCE OF SLEEP AND OF THE GENERAL 
 NUTRITION, SITOPHOBIA. 
 
 Sleep, as has been shown before (p. 90), is fre- 
 quently impaired in psychoses. Insomnia is present in 
 the beginning of almost every acute mental malady. 
 The sleep of some patients lacks the refreshing char- 
 acter of the sleep of the sane, and is reduced in intensity 
 and duration. On the other hand, there are instances in 
 which the sleep of the insane lasts much longer than the 
 sleep of healthy individuals, so that the patients are for 
 days and weeks in a continual state of somnolence. In 
 some patients this is due to hemorrhages in the dura 
 mater (pachymeningitis haemorrhagica). The blood 
 extravasate exerts a pressure on the cerebral cortex, thus 
 producing a constant state of drowziness. At the au- 
 topsy rust-colored membranes of considerable thickness 
 are found on the brain. 
 
 The general nutrition of the insane is very often 
 impaired. With the onset of a psychosis the bodily 
 
96 PSYCHE 
 
 weight of the patient decreases to rise again with the 
 beginning of convalescence or of the terminal incurable 
 stage. In some patients the hair becomes gray. This 
 canities is probably due to neurotic influences. It is of 
 common repute that care and worry render the hair gray. 
 When the patients recover, the hair may assume its 
 original color. The nutrition of the skin is sometimes 
 reduced as manifested by dryness, diminished elasticity, 
 and scaling of the epidermis. The nails become discol- 
 ored, thinner, and show grooves. The number of the 
 latter has been taken by some as an indication of the 
 number of attacks a patient has passed through. 
 
 The impaired nutritive state of the insane is fre- 
 quently due to sit phobia. Some patients have a horror 
 of food and refuse it for so long a time that they may 
 actually die of starvation. Melancholies reject food, 
 dominated by the delusion of not being worthy of nour- 
 ishment. Paranoiacs decline to eat becaUvSe of gustatory 
 hallucinations or because of the delusion that their food 
 contains poison. Other patients refuse food because 
 they have noticed that their anxiety and fear increase 
 when their stomach is filled. Hypochondriacal patients 
 imagine that they have no stomach, that the food goes 
 directly into the abdominal cavity, and try to avoid this 
 danger by abstaining from eating. Other patients try 
 to carry out suicidal plans by refusal of food. Finally 
 stuporous and some demented patients take no nourish- 
 ment for want of any feeling of hunger or because they 
 are unable to carry out the movements necessary for tak- 
 ing food. 
 
 We may mention in passing the impairment of the 
 nutritive state due to overfeeding, found chiefly in vari- 
 ous dementias. 
 
GENERAL PATHOLOGY 97 
 
 Chapter XLIX. 
 MOTOR DISTURBANCES. 
 
 Motor disturbances are not infrequent in psychoses. 
 They are of great diagnostic value. The condition of 
 the pupils furnishes significant hints. In examining the 
 pupils we must observe whether they are large or nar- 
 row, equal or unequal, and whether they react to light 
 promptly, sluggishly, or not at all. A difference in size 
 of the pupils without any other symptom does not reveal 
 which of the two is the affected pupil. If one pupil is 
 remarkably narrow or remarkably wide, we may be 
 inclined to consider this the abnormal one. In such a 
 case the mobility of the pupils decides; that pupil is 
 less affected which contracts better and more readily 
 when light is thrown into the eye and conversely. The 
 reaction of the pupils is more important than a differ- 
 ence in size. Rigidity of the pupils to light and not to 
 accommodation — Argyle-Robertson pupil — is of omin- 
 ous significance as it indicates tabes or general paresis. 
 
 Disturbance of the innervation of the tongue, occur- 
 ing in the insane, is recognized chiefly by faulty articula- 
 tion. Impaired innervation of the facial muscles is seen 
 in paretics. It also contributes to render the articula- 
 tion defective. 
 
 Some insane patients are affected with pareses and 
 paralyses of the extremities. Other patients show an 
 oblique posture of the body, or a defective gait, one leg 
 being dragged along. Closer examination of these pa- 
 tients reveals that they have no true pareses. Their 
 motor irregularities are, therefore, to be considered as 
 a disturbance of the bodily equilibrium. 
 
 Disorders of the bladder occur in some psychoses. 
 
98 PSYCHE 
 
 It can not be evacuated so that the urine is stowed up to 
 the renal pelvis. This may give rise to an ascending 
 inflammation of bladder, ureters, and kidneys — pyelone- 
 phritis. 
 
 Chapter L. 
 DISTURBANCE OF SENSIBILITY. 
 
 The occurrence of decubitus in insane patients has 
 been ascribed to tropho-neurotic disorders. But the 
 cause of the decubitus seems to be rather the result of 
 long lasting pressure on the skin. The sane person, 
 while sitting or lying, does not keep up exactly the same 
 posture uninterruptedly for a long time ; he turns a litttle 
 from side to side, he shifts his position frequently. In 
 this way the skin does not remain for too long a time 
 under undue pressure. The sane person has a delicate 
 sense of pressure so that even in sleep he becomes aware 
 of it and lessens it by slight changes of position. In the 
 insane this finer feeling is lacking. They remain mo- 
 tionless for many hours and thus gangrene of the skin 
 may be produced. It can easily be proved that tropho- 
 neurotic influences are not the cause of the decubitus of 
 the insane. In almost every case of decubitus long last- 
 ing pressure on the skin can be demonstrated, the decu- 
 bitus is never symmetrical, and the wound, with the 
 proper treatment, heals as readily as in a healthy person. 
 Finally the decubitus can be prevented by protecting the 
 patients against long lasting pressure. The decubitus of 
 the insane is, therefore, not brought about by paralysis 
 of trophic nerves, but is caused by anaesthesia of the 
 skin in consequence of which the patients make no effort 
 
GENERAL PATHOLOGY 99 
 
 t(; shun the injurious elYect of long lasting pressure on 
 the skin. 
 
 Anaesthesia of the skin is frequently met with in 
 paretic patients. They may pierce their skin with a 
 needle without manifesting a feeling of pain. Some- 
 thing similar is observed in hysteria. Owing to this 
 anaesthesia some patients may contract burns, blisters, 
 etc. 
 
 Chapter LL 
 DISTURBANCE OF THE ACTIVITY OF THE HEART. 
 
 Some writers have asserted that the insane are 
 affected with a characteristic disorder of the heart. 
 While normally the pulse curve is "tricrotic," the insane 
 have a ''tardy" pulse curve. Normally there is a rapid 
 and immediate decrease of the calibre of the artery after 
 its first distention through the blood wave ; in the ''pulsus 
 tardus," however, the arterial calibre diminishes grad- 
 ually after its first dilatation (O. T. B. Wolff). But al- 
 though the "tardy" pulse is found in the insane so often 
 that we may be tempted to regard it as a pathognomonic 
 sign of insanity, a closer investigation has demonstrated 
 that it is not characteristic of mental disease. The tardy 
 pulse is not caused by paralysis of vasomotor nerves, as 
 has been assumed, but is rather due to weakness of the 
 heart and increased resistance in the circulation at the 
 periphery. The tardy pulse is met with not only in psy- 
 choses, but also in other diseases in which these two 
 factors are present. 
 
PART III. . \ 
 
 ETIOLOGY OF INSANITY 
 
Chapter LIL 
 CLASSIFICATION OF THE CAUSES OF INSANITY. 
 
 Insanity — psychosis, alienation — is a disease of the 
 brain, especially of the brain cortex, deranging its mental 
 functions, such as perceiving, feeling, thinking, willing, 
 acting, to such an extent that the patient is unable to 
 adapt himself to his environment. 
 
 Many causes have been advanced for insanity, yet 
 its etiology is resting on a very uncertain basis. 
 
 The causes of insanity are either predisposing or 
 exciting. Most of them are both, e. g., traumatism. 
 Some causes may be regarded only as predisposing, e. g., 
 heredity. A physical injury may lower the organism's 
 power of resistance. The acquired weakness has the 
 result that at a much later period insanity breaks out in 
 direct consequence of some severe general disease, as 
 typhoid fever. In such a case the trauma is the predis- 
 posing, the typhoid fever the exciting cause. On the 
 other hand, a patient whose system has been weakened by 
 some grave disease falls readily a victim of insanity 
 when he receives a serious injury. In this instance the 
 trauma is the exciting cause. 
 
 In general it may be stated tliat anything capable 
 of injuring the general health is also apt to exert an 
 injurious influence on the resistibility and soundness of 
 the central nervous system and in tliis way may ])ecome 
 the cause of insanitv. 
 
I04 PSYCHE 
 
 Chapter LIII. 
 INFLUENCE OF CIVILIZATION. 
 
 Civilization has been considered a predisposing 
 factor of insanity. As a proof for this view has been 
 adduced the observation that in civiHzed states insanity 
 is more frequent than among unciviHzed peoples. But 
 the correctness of this observation is questionable, for it 
 is based on faulty statistics. The number of insane in 
 every thousand inhabitants has been counted — in savage 
 tribes it has been taken as reported by travellers — and 
 found to be lower in savage tribes than in civilized na- 
 tions. The conclusion has thereupon been made that in- 
 sanity is rarer among the former than among the latter, 
 and civilization has been assumed to be responsible for 
 this condition. But the argument, striking as it may 
 appear, contains the fallacy that statistics themselves are 
 a product of civilization. The statistical apparatus is 
 very much finer in civilized states than in primitive tribes, 
 and with a better apparatus higher numbers will be 
 found. To establish reliable statistics of the psychoses 
 first of all investigators are needed, capable of recogniz- 
 ing or diagnosing them. Correct statistics depend chiefly 
 upon the skill and accuracy with which the work is done, 
 and in civilized states these means are more easily ob- 
 tained. 
 
 Another proof has been advanced to show that in- 
 sanity has increased with the growth of civilization. 
 Formerly there were hardly any asylums for the insane, 
 nowadays there are many and all are overcrowded. 
 Hence the number of the insane has become larger. This 
 argument is rather weak. For in those times when there 
 were no insane asylums many cases of insanity did not 
 
ETIOLOGY OF INSANITY. 105 
 
 come to the knowledge of the authorities. With the bad 
 treatment they obtained from relatives and neighbors, 
 the mortality of the insane was enormous. Compassion 
 was accorded them, but it went only as far as the purse 
 and there it stopped. Nowadays millions are spent for 
 the unfortunates. Moreover, the diagnosis of the psy- 
 choses was very little developed and many cases of in- 
 sanity remained unrecognized on this account. Now- 
 adays there are physicians specially skilled in the 
 diagnosis and treatment of mental disease, and the pa- 
 tients who have not yet lost their free will call upon them 
 and complain about their hallucinations, compulsory 
 ideas, feelings of anxiety and fear, etc., and seek their 
 help. 
 
 Further, to demonstrate the influence of civilization 
 upon insanity, the interdependence of psylchoses and sui- 
 cide has been pointed out. . Indeed, most of the suicide 
 cases are of morbid nature. The statistics of suicide are 
 quite exact and reliable. There is hardly any error made 
 in establishing the frequency of suicide, though rarely it 
 is made a cloak for a crime. Now, statistics have shown 
 a decided increase of suicide with the advance of civiliza- 
 tion. It may, therefore, be said that the psychoses show- 
 ing a close relation to suicide have also increased through 
 civilization. This argument is somewhat conclusive. 
 
 The effect of civilization upon the frequency of gen- 
 eral paresis after syphilitic infection has been investigated 
 by some writers who find that the percentage is increased 
 in civilized lands. 
 
 Bearing in mind the preceding considerations we are 
 led to the conclusion that the psychoses have increased 
 with the progress of civilization, with the growth of 
 population and the consequent intensification of the 
 
io6 PSYCHE 
 
 struggle for existence, and with the enhancement of the 
 propensity for enjoyment and pleasure, due to civiliza- 
 tion. But this increase is not as considerable as may 
 appear from statistics and from the records of the insane 
 asylums. 
 
 Chapter LIV. 
 INFLUENCE OF RELIGION. 
 
 The question has been raised whether religious 
 creed has any influence on insanity; for in certain lo- 
 calities more insane have been found among the adher- 
 ents of one creed than among the other inhabitants. But 
 this fact does not justify the general conclusion that it 
 is due to religion as such. When in a community among 
 the Catholics, for instance, there are more insane patients 
 than among the Protestants and Jews, this does not prove 
 that creed as such is the cause. Another factor, which 
 has reference to religious creed only in an indirect 
 way, plays an important part. This factor is marriage 
 between blood-kindred. The children from such mar- 
 riages are frequently afflicted with nervous diseases, with 
 hysteria, neurasthenia, epilepsy, psychoses. Now, if in 
 a province the adherents of one creed are in considerable 
 minority, many more intermarriages will occur between 
 them than among the members of the other creeds. The 
 consequence will be that they will furnish a compara- 
 tively larger number of insane than the rest of the popu- 
 lation. 
 
 It has been maintained that the Jews have a greater 
 predisposition to insanity than the adherents of other 
 creeds. But from comparative number alone a correct 
 
ETIOLOGY OF INSANITY. 107 
 
 conclusion cannot be drawn. Other factors, too, have to 
 be considered. It is a fact that the Jewish families are 
 more solicitous for their insane patients than families of 
 other creeds. The peasant families in Europe, for in- 
 stance, are very indifferent in the care of their sick, espe- 
 cially of their insane relatives, as long as no danger 
 menaces their homes. The Jews, in their honor it must 
 be said, act quite differently. They are more easily con- 
 vinced by the physician that danger is imminent. They 
 are readily willing to go to great expenses for the sani- 
 tary welfare of their own. These factors must not be 
 overlooked. They are of great importance in determin- 
 ing the comparative prevalence of insanity among the 
 Jews. Although it cannot be denied that insanity is com- 
 paratively more frequent among them, it does not go as 
 far as has been maintained. 
 
 Chapter LV. 
 HEREDITY. 
 
 Heredity represents a very important etiological 
 factor of insanity, predisposition to mental disease being 
 more frequently due to hereditary than to any other 
 causes. 
 
 It happens quite often that parents and children or 
 several brothers and sisters are afflicted with insanity. 
 The assumption of a hereditary cause appears to be very 
 much justified in such cases. And indeed, it has long been 
 established that the descendants of the insane acquire 
 mental diseases more readily than the offspring of sane 
 people. Frequently in a family with a history of insanity 
 several members become insane, others neurasthenic, hys- 
 
io8 PSYCHE 
 
 terical, epileptic, addicted to alcohol, another commits sui- 
 cide, again another is of an eccentric character, finally 
 one distinguishes himself through extraordinary intel- 
 lectual gifts. In taking the anamnesis of a patient it is, 
 therefore, necessary to inquire not only after a history 
 of insanity, but also of such abnormal family traits. 
 
 Extraordinary intellectual gift, as a sign of her- 
 editary predisposition to insanity, has to be taken cum 
 grano salis. It is going too far to maintain unrestrict- 
 edly that the offspring of geniuses are predisposed to 
 insanity. We only may say that one-sided geniuses may 
 transmit hereditary predisposition to insanity. For while 
 in one respect they display extraordinary intellectual ca- 
 pacity, in other respects they are not free from mental de- 
 fects. In the one-sided geniuses, as it were, a compen- 
 satory development of some mental faculties has taken 
 place at the expense of the others. But if a person is 
 descended from a many-sided genius, he is to be con- 
 gratulated. For he may have inherited precious intel- 
 lectual gifts and great power of resistance of the central 
 nervous system, since he comes from an ancestor who 
 was endowed with these excellent qualities. 
 
 The foregoing remarks may be summarized as fol- 
 lows: Through heredity insanity is not transmitted di- 
 rectly, but only a certain predisposition to mental disease 
 is inherited. Psychopathic predisposition in a family is 
 indicated not only by a history of insanity, but also of 
 neurasthenia, hysteria, epilepsy, drunkenness, suicide, 
 crime, eccentricity, unusual one-sided intellectual gifted- 
 ness. 
 
 A person may have hereditary predisposition to in- 
 sanity without ever acquiring a psychosis, but he may 
 transmit his psychopathic predisposition to his offspring. 
 
ETIOLOGY OF INSANITY. 109 
 
 so that mental disease makes its appearance in the third 
 or even in a later generation. 
 
 When a person is descended from insane parents, 
 his hereditary predisposition is greater than when the 
 parents were sane and only a grand parent or a great 
 grand parent was afflicted with insanity. When both 
 parents have been insane, the children are more predis- 
 posed to mental disease than when only one parent has 
 had a psychosis. Insanity among lineal relations renders 
 the psychopathic predisposition greater than insanity 
 among collateral relations. Hence there is a manifold 
 gradation in the intensity of hereditary predisposition to 
 insanity. 
 
 If insanity has occurred among lineal relations, there 
 is a direct family history of insanity, but if only collateral 
 relations have been affected with psychoses, the family 
 history of insanity has been designated as indirect. 
 
 A family history of insanity in descending line has 
 also been spoken of. This sounds rather strange, but is 
 to be understood in the following way. When the chil- 
 dren become mentally ill, the assumption is made that 
 the parents have transmitted to them a predisposition to 
 insanity, although no direct or indirect cases of psychoses 
 can be traced in the family. Later on a psychosis breaks 
 out in one of the parents and the assumption becomes 
 true. The hereditary predisposition was, therefore, not 
 lacking, but it became manifest in the progenitors later 
 than in the descendants. The anamnesis in the case of 
 the former gives a family history of insanity in descend- 
 ing line. 
 
 Not all the children of a family possess the her- 
 editary predisposition in the same degree. Those chil- 
 dren have the greatest predisposition whose birth is least 
 
no PSYCHE 
 
 remote from the date of the illness of the parents. If 
 the parents have a family history of insanity, but have 
 never had a psychosis, the children born last have a 
 greater hereditary predisposition than those born first. 
 It is possible that the first born child remains sane all 
 through life, the second shows a manifest predisposition 
 to insanity — which will be treated later — and the third 
 becomes insane in early youth. There is, therefore, a 
 great number of gradual differences in hereditary pre- 
 disposition to insanity, and this fact is of practical impor- 
 tance. 
 
 The number of insane patients who have a family 
 history of insanity is easy to establish. In the insane 
 asylums such a history can be demonstrated in 75 per 
 cent, of the cases. The conclusion has thereupon been 
 made that of 100 people with a family history of insanity 
 75 acquire psychoses. This conclusion is fallacious. For 
 to determine how many of those giving a family history 
 of insanity become mentally sick, the question has first 
 to be decided how many people in the whole population 
 have such a history. Otherwise the problem can hardly 
 be solved. The investigation of this question is ex- 
 tremely difficult because many families conceal their 
 cases of insanity. 
 
 Chapter LVI. 
 
 STIGMATA OF HEREDITARY PREDISPOSITION TO 
 INSANITY. 
 
 The question has been raised whether hereditary 
 predisposition to insanity can be assumed only in those 
 instances in which cases of insanity, epilepsy, drunken- 
 
ETIOLOGY OF INSANITY. iii 
 
 ness, etc., have occurred among lineal or collateral rela- 
 tions, or whether also without such data hereditary pre- 
 disposition can be concluded from physical anomalies. 
 Certain abnormal features of the body, called stigmata, 
 have been found in individuals with a family history of 
 insanity and have been designated as manifest hereditary 
 predisposition in contradistinction to latent hereditary 
 predisposition ascribed to those cases in which such stig- 
 mata are absent. 
 
 Some individuals with a history of insanity show 
 deformities of the skull, such as asymmetry or obliquity. 
 The left half of the forehead, for instance, is retracted, 
 and at the same time the left half of the occiput pro- 
 trudes backwards. This may indicate that the develop- 
 ment and growth of the cranium and brain have been 
 disturbed. An eventual autopsy reveals that a cranial 
 suture has not been closed, or that a suture which is nor- 
 mally serrated has remained smooth, etc. 
 
 The facial part of the skull also shows develop- 
 mental disturbances, especially the upper jaw. Some- 
 times the suture of the palate is not situated in the me- 
 dian line, or the vault of the palate is remarkably flat or 
 remarkably narrow and high. In other cases there is 
 prognathism; normally the upper incisive teeth stand just 
 a little more forward than the lower incisors; in pro- 
 nounced prognathism, however, the upper incisors pro- 
 trude so far that a finger can be put between them and 
 the lower ones. 
 
 Faulty shape of the external ear, as lack of the helix 
 ("rat's ear") or tragus, rudimentary ear lap, etc., have 
 been brought into relation to hereditary predisposition. 
 Some dispute the connection between the two. But sta- 
 tistics have shown that deviations from the normal con- 
 
112 PSYCHE 
 
 figuration of the external ear are found more often 
 in those giving a family history of insanity than in 
 others. 
 
 Developmental disturbances of the eyes are also met 
 with in individuals with a family history of insanity, 
 such as formations of clefts in iris and chorioidea — colo- 
 bomata — excessive hypermetropia indicating insufficient 
 development and growth of the orbita. 
 
 Congenital hernias, fissures of scrotum and urethra, 
 hypospadia, clubfoot, etc., have been considered as signs 
 of arrest of development and a manifest hereditary pre- 
 disposition to insanity has been ascribed to individuals 
 showing these congenital anomalies. But nowadays the 
 view prevails that these deformities may have an external 
 cause and are of little importance. 
 
 The abnormal features mentioned before are all 
 physical stigmata. But also mental stigmata have been 
 described. It has been maintained that hereditary pre- 
 disposition to insanity is indicated by extreme nervous 
 irritability, fickleness, retiring disposition, secretiveness, 
 frequent emotional spells with lack of self-control, 
 etc. 
 
 Whether the mental and physical features described 
 above as stigmata have any relation to insanity must be 
 left undecided. Only this one fact remains certain that 
 individuals among whose relations there have been cases 
 of insanity, epilepsy, drunkenness, suicide, etc., are un- 
 questionably predisposed to mental disease. But it is to 
 be borne in mind that one affected with manifest her- 
 editary predisposition and even giving a family history 
 of insanity must not necessarily acquire a psychosis, 
 but, leading a normal quiet life, may always remain 
 sane. 
 
ETIOLOGY OF INSANITY. 113 
 
 Chapter LVII. 
 PSYCHICAL INFLUENCES. 
 
 Certain influences on the mind are apt to cause in- 
 sanity. They may be of agreeable or disagreeable nature. 
 Among the latter are to be counted fright, anxiety, worry, 
 care of sustenance, death of a near relative, vexation 
 about having been refused appreciation, about violation 
 of honor, about rejected love, etc. To the agreeable in- 
 fluences belongs joyful surprise through incidents which 
 create an extraordinary situation. Great good fortune 
 has sometimes proved fatal to the sanity of a person, 
 owing to his inability to adapt himself quickly enough to 
 the new conditions into which he has been unexpectedly 
 placed. The resistance of the central nervous system is 
 lowered through all violent agitations. Sometimes a 
 psychosis immediately follows a mental shock. 
 
 Mental strain, especially when associated with phy- 
 sical overexertion, has a dangerous effect on the mind. 
 Many soldiers who take part in military expeditions be- 
 come insane. For the hardships of war consist in great 
 physical as well as mental exertion, in fatigue, worry, 
 anxiety, etc. Officers become victims of insanity in com- 
 paratively larger numbers than common soldiers because 
 they have to go through greater mental strain than the 
 latter. 
 
 Continued mental work is productive of insanity, 
 especially when stimulants, -such as alcohol, tobacco, 
 cocaine, etc., have been used to keep up the mental ca- 
 pacity. In this respect it is of importance to know how 
 long the stimulants have been indulged in. If it can be 
 demonstrated that mental exertion was connected for 
 many years with the habitual use of stimulants, the lat- 
 
114 PSYCHE 
 
 ter is also to be counted among the causative factors 
 when a psychosis breaks out. 
 
 The question of overburdening the children in the 
 schools may be mentioned at this place, for owing to this 
 factor some children may become mentally sick. It must 
 be admitted that the same tasks are burdensome to some 
 pupils, but easy to others. The mental capacity of the 
 children, therefore, ought to be considered before send- 
 ing them to a certain school. The statement can justly 
 be made that the overtaxing of some pupils is not to be 
 placed at the door of the schools, but is to be put to the 
 account of the parents who send their children to schools 
 the requirements of which they are unable to fulfill. 
 
 The influence of imprisonment upon the mental 
 health belongs to this chapter. When one is deprived of 
 his liberty, especially when he is put in solitary confine- 
 ment, he begins to suffer mentally. Uneducated prison- 
 ers whose funds of knowledge are too meagre to afford 
 them entertainment with their own thoughts, become more 
 readily mentally ill than more intellectual ones. Another 
 factor contributing to produce mental disease in prison- 
 ers is the poor state of their general health brought about 
 by the unfavorable conditions prevailing in prisons. The 
 general nutrition is greatly impaired, owing to poor food 
 and to lack of fresh air and light. This shows itself by 
 considerable loss of weight. It requires the indifference 
 and imperturbability of the habitual criminal to take on 
 weight during imprisonment. Confinement before trial 
 may sometimes produce a psychosis. This point is of 
 great importance for the medico-legal expert. The pris- 
 oner may have been perfectly sane at the time of com- 
 mitting the crime, while at the trial he is mentally de- 
 ranged, owing to the preceding confinement. 
 
ETIOLOGY OF INSANITY. 115 
 
 Chapter LVIII. 
 INFLUENCE OF INFECTIOUS DISEASES. 
 
 A frequent etiological factor of insanity are the in- 
 fectious diseases, as typhoid fever, scarlatina, cholera, 
 etc. Their effect on the central nervous system is two- 
 fold. In the first place they cause acute poisoning 
 through toxines which act on the brain, giving rise to 
 acute mental disturbances in the form of deliria. The 
 latter have formerly been attributed merely to the high 
 temperature. But the rise of temperature alone is not 
 sufficient to explain the so-called fever deliria. For some 
 patients with high temperature are little benumbed, while 
 others with low fever may exhibit strong mental aliena- 
 tion. 
 
 Secondly, the infectious diseases have a more perma- 
 nent weakening effect on the nervous system, so that the 
 patients retain a predisposition to mental disease and thus 
 acquire psychoses at a later period. Just as diphtheria 
 even of slight severity may, months later, give rise to 
 diphtheritic paralyses, so may psychoses appear long 
 after the infectious diseases. The patient may overcome 
 his illness with comparative ease, but as a consequence 
 his nervous system may retain diminished resistibilty to 
 external influences. 
 
 Mental disorders occur in early and late stages of 
 lues. In general paresis — and similarly in tabes — the 
 percentage of cases in which there is a history of syph- 
 ilitic infection is so high that these diseases have come 
 to be regarded as late luetic manifestations. Some, how- 
 ever, have held the view that general paresis and tabes 
 do not represent luetic symptoms, and have given an- 
 other explanation for the frequent occurrence of these 
 
ii6 PSYCHE 
 
 diseases in syphilitics. They compare the effect of lues 
 on the system to that produced by the acute infectious 
 diseases. As in these so also in lues the resistibility of 
 the system is greatly reduced by toxines and thereby a 
 strong predisposition to nervous diseases is imparted to 
 the patients. The fact that lues can be excluded in a fair 
 percentage of cases seems to justify this view. The latter 
 will hardly agree with the results of recent sero-diag- 
 nostic investigations. For some authors maintain that 
 the sero-diagnostic examination of the blood and the 
 cerebro-spinal fluid of paretics shows a positive syphilitic 
 reaction in lOO per cent, of the cases. But since these 
 findings have not yet been fully corroborated, the above 
 view is not untenable. 
 
 Chapter LIX. 
 INFLUENCE OF POISONS. 
 
 An etiological factor of insanity is furnished by 
 poisoning with various organic and inorganic substances. 
 In all exactness, the effect of the infectious diseases is also 
 of a poisonous — toxic — character; at least, we cannot 
 explain it in any other way. They might, therefore, as 
 well have been included in this chapter. But while the 
 poisonous substances mentioned here are well known, the 
 toxines of the infectious diseases have not yet been iso- 
 lated, and their exact nature is still unknown. This is the 
 reason why their influence upon the mind has been dis- 
 cussed separately from other poisons. 
 
 Among the organic poisons alcohol, in the form of 
 spirituous liquors, takes the first place in the causation 
 
ETIOLOGY OF INSANITY. 117 
 
 of insanity. The degree of the alcoholic concentration is 
 important, whiskeys and brandies being more injurious 
 than wine and beer, heavy wines and beers more deleteri- 
 ous than light ones. The quality of the alcoholic bever- 
 ages is also of great moment. The worse the brand of 
 the liquor, the more impurities it contains, as the fusel 
 oils, and the more harmful it is. 
 
 Alcohol has first an acute effect on the mind. In a 
 strict sense, the alcohol intoxication represents an acute 
 psychosis. More manifold are the psychopathic conse- 
 quences of chronic abuse of alcohol. The chronic al- 
 coholic may unexpectedly become insane with the clin- 
 ical picture of delirium tremens when he is deprived of 
 his habitual stimulant. The deprivation from the alcohol 
 occurs when a drunkard is arrested and put into prison. 
 Delirium tremens may break out, owing to the lack of 
 the stimulant. The prison physician ought, therefore, 
 to see to it that alcoholics just made prisoners receive a 
 certain amount of alcohol. Another occasion in which 
 the alcohol is suddenly taken away from drunkards is a 
 physical illness. When they are brought into the hos- 
 pital, and they themselves are not even able to ask for 
 alcohol, they may be seized with delirium tremens over 
 night. 
 
 Alcoholics are predisposed to many diseases and 
 readily become victims of any injurious influences. 
 Traumas produce mental disturbances in inebriates more 
 frequently than in temperate people. When deprived of 
 their liberty, drunkards succumb to the deleterious influ- 
 ences of prison life much sooner than other prisoners 
 (p. 114). 
 
 Mental disorders are brought about through poison- 
 ing with hypnotics and other drugs, such as morphine, 
 
ii8 PSYCHE 
 
 opium, chloral hydrate, cocaine, atropine, etc. Chronic 
 morphinism has become quite frequent since the hypo- 
 dermic injection of morphine has come into use, the med- 
 ical profession being responsible, to a great extent, for 
 this regrettable fact. Chloral hydrate is often pre- 
 scribed for insomnia. Like other hypnotics it has the un- 
 toward feature that the organism becomes accustomed to 
 it. Larger and larger doses have to be taken by the pa- 
 tient, who passes sleepless nights without the remedy. 
 After long use mental disorders similar to those of 
 chronic morphinism make their appearance. Acute poi- 
 soning with cocaine causes agitation, inhibition of speech 
 and of thinking, stupefaction, etc. The chronic abuse of 
 cocaine is productive of mental disorders and marasmus 
 and brings about the fatal end much sooner than chronic 
 morphinism. Atropine in large doses causes deliria, so 
 does iodoform after protracted application. Poisoning 
 with mercury, lead, arsenic also produces mental distur- 
 bances. Secale cornutum is to be mentioned here. Flour 
 corrupted with this parasitic fungus brings about a dis- 
 ease similar to general paresis. In provinces where much 
 maize is consumed insanity is quite frequent — pellagra. 
 
 Chapter LX. 
 INFLUENCE OF TRAUMA. 
 
 Physical injuries, especially of the skull, play an 
 important role in the etiology of insanity. All violent 
 commotions of the body, brought about by fall or im- 
 pact, are apt to cause neuroses and psychoses. Fre- 
 quently even serious injuries remain without any psycho- 
 
ETIOLOGY OF INSANITY. 119 
 
 pathic after-effects. Many a head has received blows of 
 no little force without the slightest mental disorder ap- 
 pearing shortly after the injury or at a later period. 
 Often a psychosis follows the trauma immediately. 
 Sometimes, however, the effect of a trauma upon the 
 mind does not appear before many years have elapsed. 
 Some disturbances of the general health arise immedi- 
 ately after the injury, such as headache, sleeplessness, 
 great irritability, intolerance of alcohol, etc. A thread 
 of such little ailments is thus spun for a long time until 
 the outbreak of a psychosis, v 
 
 In trauma as an etiological factor of mental disease, 
 therefore, cause and effect may lie far apart. This holds 
 good also with other influences productive of insanity. 
 This point has formerly not been appreciated sufliciently, 
 and therefore the influence of lues has been overesti- 
 mated. Many a psychosis has been attributed to lues, 
 although its cause may have been a distant trauma, for- 
 gotten long ago, or a severe illness which the patient had 
 been afflicted with at some remote period, and which had 
 diminished the resistibility of his central nervous system. 
 
 The harmfulness of a trauma is, as a rule, directly 
 proportionate to the disturbance of consciousness fol- 
 lowing the trauma, so that the more the consciousness of 
 the patient has been obtunded by the injury, the more 
 the injury is likely to become a cause of insanity. An 
 error may be committed in assuming that an injury has 
 not been succeeded by disturbance of consciousness. A 
 patient who has been unconscious after a violent fall, does 
 often not know anything about it, unless he has heard 
 it from others. Questioned in this regard he, therefore, 
 denies having been unconscious after the fall. 
 
 Slight injuries without disturbance of consciousness 
 
I20 PSYCHE 
 
 may also be of serious consequence to the mental health. 
 Thus an injury of the skull may leave a depressed scar 
 giving rise to psychoses many years later. The irritation 
 of the cerebral cortex through the scar may produce epi- 
 leptic attacks or their psychic equivalents (pp. 243-244). 
 
PART IV. 
 
 COURSE (PROGNOSIS) AND THE- 
 RAPY OF THE PSYCHOSES 
 
SECTION I. 
 
 COURSE (PROGNOSIS) OF THE PSY- 
 CHOSES 
 
 Chapter LXI. 
 ONSET OF THE PSYCHOSES. 
 
 From the etiological factors described in the pre- 
 ceding part the psychoses develop in two ways. The 
 onset of some mental diseases is surprisingly rapid, in 
 others it is gradual and imperceptible, the cause, as a 
 rule, determining whether it is to be precipitous or in- 
 sidious. 
 
 Rapid onset characterizes the deliria. They appear 
 as soon as intoxication has taken place. Especially de- 
 lirium acutum (p. 26^), the essence of which is yet 
 unexplained, is marked by a very abrupt onset. The 
 deliria of abstinence (p. 259) occurring in alcoholics, 
 morphinists, etc., may also begin suddenly. When the 
 habitual stimulant has been withheld from the alcoholic 
 for a single day, delirium tremens may follow forthwith. 
 The traumatic psychoses very often set in suddenly. A 
 person falls out of the window, loses consciousness, re- 
 gains it after some time, and in the course of the same 
 day he may manifest symptoms of insanity. 
 
 Much more frequent is the slow development of the 
 psychoses. General paresis has a prodromal stage of 
 many months' duration. Other psychoses are preceded 
 by a stage of depression so commonly that some authors 
 
124 PSYCHE 
 
 have sought to maintain that every mental malady is 
 ushered in by a preliminary depressive stage. But for 
 this broad statement there is not enough justification, a 
 preliminary depressive stage, although very frequent, 
 being absent in a good many instances. 
 
 Sometimes the psychoses develop so slowly and im- 
 perceptibly that the relatives of the patient are unable to 
 determine the date of the onset. The beginning of many 
 psychoses is so insidious that it is overlooked, and to lay- 
 men it appears as though the attack had commenced all 
 of a sudden. But closer questioning reveals that the 
 patient, while yet sailing along under the flag of health, 
 on occasions displayed evidences of insanity. Often the 
 relatives retrospectively become positive about the begin- 
 ning of a psychosis. When unmistakable signs of in- 
 sanity appear, they comprehend and admit that the for- 
 mer, more or less noticeable, changes in the character of 
 the patient already marked the beginning of his mental 
 malady. 
 
 In the psychoses with slow development the initial 
 symptoms are frequently mistaken for the cause of the 
 disease. Thus in the beginning of general paresis the 
 patient may exhibit many extravagances. He spends 
 much money, drinks immoderately, and commits other 
 excesses. Through all this he does not arouse the sus- 
 picion of neighbors and relatives; for he does not yet 
 talk "nonsense," as laymen would say. The disease then 
 progresses and becomes pronounced, so that the patient is 
 recognized as insane even by laymen. Now the cause of 
 the psychosis is attributed to the former immoderate 
 drinking and to the other excesses. And yet these were 
 already the initial symptoms of the mental malady. 
 
 It is necessary to be acquainted with these facts in 
 
COURSE OF THE PSYCHOSES 125 
 
 order to be able to determine as nearly as possible the 
 beginning of a psychosis. In modern society the life of 
 one man is so intimately bound up with the affairs of 
 other people that the beginning of a psychosis cannot be 
 regarded as something individual and not affecting 
 others. Often great fortunes are at stake, their just dis- 
 tribution depending upon whether or not it can be proved 
 that at a certain time their rightful owners were already 
 suffering from mental disorders. If a person in the be- 
 ginning of a psychosis has deeded away his property to 
 strangers without the knowledge of his family, the de- 
 serving may be deprived of what is their due, unless the 
 time of onset of the mental disease can be established. . 
 
 Chapter LXII. 
 DURATION OF THE PSYCHOSES. 
 
 The course of the psychoses also shows great varia- 
 bility. There is a rapid and a protracted course, and 
 there are all possible forms intermediary between the 
 two. 
 
 The entire course of a psychosis may be included in 
 a single day. Especially the deliria furnish many ex- 
 amples of this kind. In the so-called mania transit oria 
 the patient is suddenly seized with a fit of raving mad- 
 ness and is well again on the following day. The whole 
 process usually terminates with the patient falling into a 
 long sleep from which he awakes with little recollection 
 of what has transpired. Great caution must be exer- 
 cised in terming a psychosis mania transitoria. This 
 diagnosis is so often unjustifiably made that one might 
 
126 PSYCHE 
 
 think mania transitoria were a frequent psychosis, which 
 is far from the truth. Mahngerers may adduce this dis- 
 ease as a pretext for their misdeeds. 
 
 Psychoses of an abrupt onset and rapid course 
 occur in epilepsy. All of a sudden the patient falls into 
 a state of confusion and commits all kinds of excesses. 
 After several hours or on the following day his mind 
 is entirely clear again. The course of such psychic 
 equivalents of the epileptic attacks (pp. 243-244) is not 
 always so exceedingly rapid. Sometimes they last sev- 
 eral weeks, but the short duration is more frequent. 
 Something similar is observed in hysteria in which psy- 
 choses of two or three days duration occur. 
 
 More frequent is the slow course of the mental dis- 
 eases. In general the psychoses last for months, so that 
 we cannot yet speak of a protracted course in a mental 
 malady of several months' duration. 
 
 Some psychoses are characterized by a periodic 
 course. Thus a patient enters the insane asylum with 
 the symptoms of acute mania, leaves the institution after 
 some time apparently cured, and returns after several 
 months or a year in a maniacal condition. One may be 
 inclined to speak of a relapse in such a case; but the ex- 
 perienced alienist will at once think of periodicity of the 
 disease. And indeed, the patient having been dismissed 
 as cured for the second time, comes back into the asylum 
 after another interval. In such an instance we are not 
 dealing with ordinary mania of comparatively favorable 
 prognosis, but with periodic insanity of incurable nature. 
 Usually the mania is repeated until the patient finally 
 passes into a state of secondary dementia (p. 189). 
 
 As a rule the periodic course of psychoses is such 
 that maniacal stages alternate with free intervals. In 
 
COURSE OF THE PSYCHOSES 127 
 
 some instances, however, it shows the circular character, 
 mania alternating with free and melancholic intervals. 
 Psychoses with this cyclic character are also of very 
 unfavorable prognosis (pp. 240-241). 
 
 The course of other psychoses is extremely long- 
 lasting and continuous or almost continuous. Some pa- 
 tients remain in the insane asylum for a score of years 
 and longer. 
 
 Some psychoses have an irregular course, being 
 marked by exacerbations and remissions of varying 
 duration. Remissions are frequent in general paresis. 
 A common error committed by the inexperienced in re- 
 gard to general paresis is to declare the patient as cured 
 in a remission. Not enough stress, therefore, can be 
 laid on the fact that in the course of general paresis 
 periods do occur during which the patient appears en- 
 tirely free from all morbid symptoms. The relatives 
 of the patient are easily misled by such a remission. 
 They argue the patient is so intelligent, amiable, speaks 
 so sensibly, that <^they cannot help regarding him as en- 
 tirely well again. He ought to return home. They take 
 the patient away from the asylum, convinced that the 
 psychiatrist has this time made a mistake in giving 
 originally a bad prognosis and in advising extreme 
 caution in the future. But after a few years they bring 
 the patient back into the institution and admit that their 
 medical adviser was right in his statement that the im- 
 proved condition of the patient was merely a remission. 
 The error of declaring a paretic as sane in a remission 
 happens not only to laymen, but also to physicians. A 
 deficient pupillary reaction, a weakness of the legs, a 
 disturbance of the handwriting, an insignificant impedi- 
 ment of speech, may furnish a hint that the patient is 
 
128 PSYCHE 
 
 not entirely cured, but is in a stage of remission. The 
 duration of these remissions is generally only a few 
 months, but sometimes they may continue several years. 
 Something similar occurs in paranoia. A patient is 
 brought into the asylum suffering from delusions of 
 furtherance and grievance. After some time he ceases 
 speaking about these delusions, and it is hardly possible 
 to recognize whether or not he has abandoned them. His 
 behavior becomes orderly, and he is released from the 
 institution. After a few years he returns with new delu- 
 sions or the same ones, and it looks as if the disease had 
 started at the point where it had ceased. The duration 
 of such remissions is not always so long; sometimes the 
 disease becomes manifest again after a few months with 
 the appearance of new delusions or the recurrence of the 
 same ones. 
 
 Chapter LXHL 
 TERMINATION OF THE PSYCHOSES. 
 
 The psychoses may terminate in convalescence fol- 
 lowed by complete recovery. When the pathological 
 process is nearing its end, the morbid symptoms grad- 
 ually disappear. The confusion ceases, the delusions 
 are corrected, the restlessness abates, the body weight in- 
 creases, etc. The convalescence may pass into complete 
 recovery or the psychosis may be repeated. One of the 
 most important means we have at our disposal to de- 
 termine whether or not recovery has taken place, is the 
 patient's opinion about himself and about those who had 
 taken care of him during his illness. When the patient 
 has recovered, he gains the "insight into the disease," 
 
COURSE OF THE PSYCHOSES 129 
 
 He recognizes and admits willingly that he was sick, that 
 the measures taken in his case were necessary and aimed 
 at his welfare. He feels and manifests a certain grati- 
 tude towards his physician and his attendants. 
 
 The "insight into the disease" furnishes the most 
 valuable criterion for recovery. For while the process 
 of mental disease is still active, the patients do not deem 
 themselves sick, but believe to be unworthy, persecuted, 
 nabobs, powerful potentates, proteges of kings, etc. This 
 characteristic sign of complete recovery is especially of 
 great importance since it renders possible the differentia- 
 tion of a free interval of periodic insanity from actual 
 recovery. In such an interval the patient has the in- 
 sight into the disease only to a slight degree. He is 
 little impressed with, and underestimates, the impor- 
 tance of his disease, arguing after this manner: 'Tt is 
 true, I have been somewhat excited and feeling ill at 
 ease, but now I am entirely composed and perfectly 
 well, and it is not at all possible that I would fall 
 sick again." And yet the fact that he has gone through 
 the same sickness perhaps half a dozen times, and has 
 held the same opinion after every attack, ought to make 
 him consider the possibility of a return of his illness. No 
 strong intellectual capacity would be required for that 
 thought. But just this lack of proper judgment in re- 
 gard to his mental health is a sign that there is yet 
 some imperceptible disorder in the mechanism of his 
 psychical functions, although to all appearances they are 
 entirely normal again. The patient has a wrong opinion 
 about himself, due to a disturbance in the affective sphere 
 that still remains after the disappearance of all the other 
 symptoms of mental disease. A morbid feeling of being 
 unfailingly sound is still extant in the patient and pre- 
 
130 PSYCHE _ 
 
 vents the arising of any thought that the condition of his 
 health is apt to change again. 
 
 Some patients dismissed as convalescent do not gain 
 the full insight into their disease before an interval of 
 about half a year has elapsed. Then they tell the physi- 
 cian until this moment they did not realize that their 
 mental health was impaired, now they do and at the same 
 time they feel that it has been fully restored ; now they are 
 able to appear before him without that feeling of anxiety 
 and fear which up to that very moment they still experi- 
 enced in his presence. 
 
 There are cases, however, in which the patients, 
 though entirely well again in body and apparently also 
 in mind, do never regain the insight into their disease. 
 In such an instance the psychosis has terminated with a 
 certain mental defect. This represents the second form 
 of the termination of the psychoses; the preceding acute 
 mental disease has brought about a permanent impair- 
 ment of acuity of understanding, of warmth and mani- 
 foldness of feeling, of nobility of character, etc. There 
 are numerous gradations and transitions from these slight 
 psychical defects to the mental states comprised in com- 
 plete dementia. 
 
 Fixed delusions (Ch. 30, p. 59) remaining after an 
 acute psychosis indicate that it has terminated in secon- 
 dary mental weakness. The patient appears normal 
 again, but closer examination shows that he still harbors 
 erroneous ideas on certain subjects. It is impossible to 
 convince the patient of their absurdity, and he is unable 
 to abandon or correct these delusions. The preceding 
 acute mental disorder has left a permanent impairment 
 of the ideational and emotional sphere, finding its ex- 
 pression in these fixed delusions. Although in all other 
 
COURSE OF THE PSYCHOSES 131 
 
 respects and to all practical purposes the patient's mind 
 may be intact, healing with a mental defect has taken 
 place in such instances. 
 
 Very frequently the mental defects remaining after 
 acute psychoses are so considerable and manifold that 
 we cannot at all speak of healing or recovery. In such 
 cases the acute pathological process has resulted in sec- 
 ondary dementia. 
 
 Some psychoses terminate in death. This does not 
 refer to those cases in which the exitus lethalis was 
 brought about by a misfortune that could have been pre- 
 vented, for instance, by intentional suicide of the patient 
 or by a fatal accident. But only those cases are included 
 in this category where death, as it were, follows as a 
 natural consequence of the pathological process. Gen- 
 eral paresis ends in death, so does delirium acutum. 
 
SECTION II. 
 THERAPY OF INSANITY 
 
 Chapter LXIV. 
 
 COMMON RELUCTANCE TO INSTITUTIONAL 
 
 TREATMENT OF THE INSANE; RESPON= 
 
 SIBILITY OF THE FAMILY PHYSICIAN. 
 
 The treatment of the insane has made great progress 
 since the age of superstition when they were regarded as 
 mahcious individuals possessed by the evil spirit and 
 eager for crime. They are now universally recognized 
 as unfortunates afflicted with diseases of the brain. This 
 view has become productive of a more humane handling 
 of the insane. Modern psychiatry may be said to date 
 altogether from that time. But even to the present day 
 a very considerable part, if not the majority, of the in- 
 sane of a country are not in public asylums, but under 
 inadequate private care or at large. For in many families 
 an aversion prevails against committing their insane pa- 
 tients into an asylum, not because they fear bad treat- 
 ment, but because in a public institution a case of in- 
 sanity cannot be concealed. To divulge a case of insanity 
 is deemed injurious for social reasons. The importance 
 of hereditary predisposition is not underestimated, and 
 the public knows the danger of marriage into a family 
 with a history of insanity. 
 
 Because of this common reluctance to institutional 
 treatment of the insane it devolves upon the family 
 
THERAPY OF INSANITY 133 
 
 physician to handle cases of insanity, and he ought, 
 therefore, to be acquainted with their treatment. The 
 relatives of the patient will say to the family physician 
 they have so much confidence in his experience and skill 
 that for their part he may conduct the treatment all alone 
 as long as he feels able to assume the responsibility. The 
 question is then whether and how long he shall take the 
 responsibility upon himself. Evidently a maniac has to 
 be removed to an asylum without much delay. But a 
 harmless patient suffering from secondary feeble-minded- 
 ness or an idiot may be treated in his home. To some 
 extent this holds good also with the milder forms of 
 melancholia. Little importance may be attributed to the 
 suicidal utterances of the melancholies in a state of de- 
 pression. But the danger of suicide is very great when 
 the depression is increased to an emotional spell of an- 
 xiety and fear. When such spells occur often, the 
 physician must warn the relatives of the imminent dan- 
 ger of suicide and emphasize that it can be prevented 
 only in an institution. If they still resist commitment 
 to an asylum, he should rather give up the case than take 
 further responsibility. For when a misfortune does oc- 
 cur, he will certainly receive the blame for it and be 
 accused just by those who had assured him of their un- 
 limited confidence and had offered the most emphatic 
 resistance to sending the patient away from the home. 
 The very same people will throw the first stone at the 
 physician and will lay the misfortune at his door, main- 
 taining that he did not insist sufficiently upon removing 
 the patient to an asylum. After relinquishing the case, 
 the physician should, under certain conditions, report it 
 to the proper magistrates so that they may prevent a 
 calamity. 
 
134 PSYCHE • , 
 
 Chapter LXV. 
 
 TRANSPORTING INSANE PATIENTS TO THE 
 ASYLUM. 
 
 When the relatives of an insane patient have de- 
 cided to place him into an asylum, the physician must 
 help them with his advice and supervise the transporta- 
 tion. As a rule force has to be used, for the removal 
 from the home must usually be carried out against the 
 will of the patient. Certain conditions are, therefore, to 
 be fulfilled. First of all somebody must be present who 
 has the right to transfer the patient to an asylum against 
 his will. Some patients, even after their recovery, bear 
 a grudge against those who had deprived them of their 
 liberty. They even harass them with legal proceedings 
 on that account. It is, therefore, advisable for the physi- 
 cian to be well informed about the relatives' right to com- 
 mit the patient to an asylum. There can be no doubt 
 about the right of a husband to place his legally insane 
 wife into an asylum, and conversely. The same right 
 appertains to the parents towards their children under 
 age. But it may be doubted whether brothers and sisters 
 have that right towards each other. With paretics or 
 with patients suffering from secondary dementia it will 
 not be difficult to come to a decision regarding the right 
 of commitment, since their future resentment for re- 
 straint of their liberty may be dismissed because of the 
 incurability of the disease. 
 
 Frequently when a patient is violent and offers re- 
 sistance to the removal from home, the request is made 
 by the relatives that no force be used, that the physician 
 should, in some way, lure the patient into the institution 
 without arousing his suspicion. In some instances this 
 
THERAPY OF INSANITY 135 
 
 can be accomplished without difficulty, as with paretics 
 in a maniacal stage. But if the patient is intelligent 
 enough to recognize the purpose of the journey, ruse 
 should not be resorted to. For he is likely to find it out, 
 and then he may become violent and perhaps escape. 
 Now, in a case where deception is contraindicated there 
 remains nothing else but to tell the patient openly that 
 he must go to a hospital whether he wants it or not. Be- 
 fore communicating this to him certain measures must 
 be prepared. All dangerous implements must be re- 
 moved and windows and doors secured so as to render 
 escape impossible. The physician must surround him- 
 self with a sufficient number of attendants to prevent any 
 violent act of the patient either against himself or 
 against others. 
 
 If necessary, the physician should not hesitate to 
 make use of the strait- jadcet during the transport. With 
 this implement two attendants can accomplish the de- 
 sired end, while otherwise four would hardly suffice. 
 Without the strait- jacket it is sometimes necessary to 
 shackle the patient. This, on one hand, is very disagree- 
 able to the patient and, on the other hand, is not without 
 danger. At the place where the shackles press the skin 
 gangrene may be produced because the patient does not 
 try to avoid the pressure (Ch. 50, p. 98). 
 
 The ordinary strait- jacket is a coat reaching down 
 below the hips, closing in the back, and provided with 
 long sleeves to the anterior ends of which are attached 
 strong leather straps. The jacket is put on in the fol- 
 lowing way: An attendant sticks his left hand into the 
 right sleeve, through its anterior end, and his right hand 
 into the left sleeve, and shoves the sleeves over his arms 
 vmtil the hands come out through the posterior openings. 
 
136 PSYCHE 
 
 Now he approaches the patient who is held on both sides, 
 grasps one wrist, and shoves the sleeve over the patient's 
 arm. The same is done with the other wrist and arm. 
 The arms are then crossed and the straps brought to- 
 gether on the back and tied. In this way three attendants 
 are usually able to master any patient even if he resists 
 and struggles. There are patients, however, who can 
 not be put into the strait-jacket even with the greatest 
 of efforts. In such cases there remains nothing else ex- 
 cept to apply a general anaesthetic. For after the physi- 
 cian has once resorted to force, he ought not to withdraw 
 under any circumstances without having attained the de- 
 sired end. Deep narcosis is not necessary. The more 
 the patient struggles, the stronger he inhales the anaes- 
 thetic and the sooner he becomes unconscious. 
 
 When a violent patient in a strait- jacket is to be 
 brought into the carriage, it is advisable to put a cloak 
 around him to spare the public the disgusting sight of 
 the strait- jacket. In the city the police authorities ought 
 to be informed that a violent insane patient is to be trans- 
 ported somewhere, otherwise when the patient becomes 
 turbulent and vociferous, a tumult may arise and an 
 unfortunate incident occur. 
 
 When an insane patient is to be transported to the 
 asylum by rail, he must be brought to the station and into 
 the car before the other traveling public arrives. The 
 railroad administration must be notified beforehand of 
 his transportation. If the patient is violent or has uttered 
 the slightest suicidal intentions, two attendants must 
 guard the windows near him. He must not be per- 
 mitted to be alone for a moment. At least one female 
 nurse should accompany a female patient. 
 
 It is very difficult to master a violent patient who 
 
THERAPY OF INSANITY 137 
 
 threatens to make use of a weapon if anyone should 
 approach him. Nothing can be accomplished in such 
 an instance with mere force, but some artifice is to be 
 resorted to. The physician must see to it that some re- 
 liable person be in the room with the patient. It will 
 scarcely be the case that he will not permit anyone what- 
 soever to be near him. While this person tries to occupy 
 the patient's mind, the physician, at a favorable moment, 
 enters the room with several attendants, thus surprising 
 the patient with superior force. Two of the attendants 
 must have been instructed beforehand not to wait for 
 any further orders, but to get at once behind the patient, 
 one at each side. The physician steps in front of the 
 patient and begins to divert his attention. At this mo- 
 ment he is grasped at each arm by the attendants in back 
 of him. Immediately all his pockets are thoroughly 
 searched and all dangerous implements taken away. It 
 is altogether a strict rule not to commence the transport 
 to the asylum of any insane patient without searching 
 him for dangerous instruments. 
 
 Even harmless patients, from the time they have 
 found out that they are to be transferred to the insane 
 asylum, must never be left alone for a moment. 
 
 During the transport no utterance whatsoever con- 
 cerning the insane asylum or the treatment should be 
 made in the presence of the patient. 
 
 Chapter LXVI. 
 INSANE ASYLUM. 
 
 The objection has been raised against institutional 
 treatment of the insane that their disease may become 
 aggravated when they are surrounded by unfortunates 
 
13B PSYCHE 
 
 like themselves and see their pitiable plight, thereby more 
 readily comprehending their own misfortune. This dis- 
 advantage has to be put up with as it can hardly be 
 avoided, especially with patients in ordinary financial cir- 
 cumstances. On the other hand, the disadvantage is 
 outweighed by the benefits arising from treatment away 
 from home. As in other nervous diseases so also in psy- 
 choses it is best for the patient to be taken away from 
 the conditions and the environment in which he has been 
 living up to that time. This advant^ige is most easily 
 obtained by removal of the patient into an institution. 
 The chief benefit of asylum, treatment, however, consists 
 in the patient being withdrawn from, and protected 
 against, many dangers hardly avoidable while he is un- 
 der care in his own home, such as refusal of food, 
 attempt at escape or at suicide, etc. 
 
 The principles to be followed in the insane asylum 
 must be purely medical, i. e., the insane are to be treated 
 as patients. They must share the benefits that have 
 accrued from the progress of science for all those 
 afflicted with disease. All hygienic requirements must 
 be fulfilled in the asylum. It must have a good situation, 
 good ventilation, good air, good light, good water sup- 
 ply, and good regulation of the temperature of the rooms. 
 Furthermore, there must be different departments in the 
 institution. Aside from the separation into a male and 
 a female division there must be different wards accord- 
 ing to the different ways the patients conduct themselves. 
 In one department are placed quiet patients not needing 
 extraordinary watching, in another one patients who are 
 very restless, again in another one patients who do not 
 keep themselves clean, etc. A separate department is to 
 be fitted up for patients who would use any object as a 
 
THERAPY OF INSANITY 139 
 
 weapon against themselves and others. Here everything 
 must be clinched and riveted. It must be impossible to 
 move chairs, to upset tables, etc. Further, there must be 
 special wards for patients needing extraordinary watch- 
 ing. Into these wards are put also those patients who 
 have just entered the institution, and whose conduct has 
 first to be determined before bringing them into the 
 wards adapted for them. Moreover, the social circum- 
 stances of the patients are to be taken into consideration 
 in establishing an asylum for the insane. 
 
 An insane asylum should be constructed to accom- 
 modate no more than 500 patients in order that one 
 physician may be able to superintend it, which is a very 
 important point for the successful work of the institu- 
 tion. Since many patients can and ought to be occupied, 
 sufficient gardens must be provided. There are several 
 systems of insane asylums. In the closed institutions 
 the various buildings are connected, in the pavilion sys- 
 tem they are separated, and in the agricultural institutions 
 special provisions are made for an agricultural occupa- 
 tion of the patients. The first system is best adapted for 
 the neighborhood of big cities because of the saving of 
 ground and because of the easy frustration of attempts 
 at escape. Even these closed institutions must have 
 enough garden grounds. The pavilion system is appro- 
 priate for country sanitaria. It has this disadvantage 
 that the physician cannot easily overlook everything and 
 cannot come unseen into the different departments. The 
 agricultural institutions offer the best advantages with 
 respect to the occupation of the patients and with respect 
 to the prevention of certain diseases so frequent in the 
 closed institutions, as tuberculosis. They are naturally 
 adapted only for the country. If it is possible to erect 
 
I40 PSYCHE 
 
 several insane asylums in a district, it is advisable to 
 make use of more than one system. 
 
 One person, and that a physician, is to be vested 
 with supreme authority in the asylum, all other officials 
 should be subordinate to him. If they are coordinate, a 
 dualism reigns in the institution which cannot fail to be 
 prejudicial. 
 
 A reliable staff of nurses is indispensable for an 
 insane asylum. They must be obedient, consciencious, 
 must have entered into hospital service in early years, 
 and must follow their occupation with a certain love and 
 devotion, being content with the disagreeable sides and 
 arduous tasks of the care of the sick. Since stability of 
 the nurses' staff is a great requisite, it should consist only 
 of people who have made the care of the sick their call- 
 ing in life and, therefore, remain in the asylum perma- 
 nently. All this can be attained only by giving the nurses 
 ample pecuniary compensation and assurance of a suffi- 
 cient pension after a faithful service of a number of 
 years. The nurses should receive regular instruction. 
 If after one year's service a nurse proves not to possess 
 the proper qualification for his position, he is to be dis- 
 missed. 
 
 A staff of competent assistant physicians is very 
 requisite. For every hundred patients there ought to be 
 at least one assistant. 
 
 In the treatment of the patients mechanical com- 
 pulsion is to be restricted to the most desperate cases. 
 Care must be taken that patients with destructive ten- 
 dencies may not harm themselves, that the institution 
 be provided with clothes difficult to tear, that there be 
 enough space in the wards so that the patients need not 
 lie close to each other, that there be enough room for 
 
THERAPY OF INSANITY 141 
 
 isolation and a sufficient number of attendants. Only 
 then the strait- jacket may be dispensed with. Sometimes, 
 however, it is absolutely necessary, as in surgical cases. 
 A violent patient with a fracture of the leg must even be 
 chained to the bed. 
 
 The general treatment must be humane. The at- 
 tending physician should not excite the patient by his 
 visit. In refusing unjustified wishes of the patient he 
 should act in a manner that will not hurt his feelings. 
 He should never make the patient feel his superiority, 
 and should never bear a grudge against a patient for dis- 
 respect or ill behavior. To fulfill all this is not at all 
 easy and has to be learned by experience. 
 
 Mechanical compulsion in the treatment of insane 
 patients in the past may be excused when one bears in 
 mind the insufficient means then at the disposal of the 
 institutions. 
 
 Chapter LXVII. 
 
 TREATMENT OF THE INDIVIDUAL SYMPTOMS 
 OF INSANITY. 
 
 Morbid Mood. A patient laboring under morbid 
 depression must be left alone. All efforts to cheer him 
 up, to make him participate in entertainments and pleas- 
 ures are anything but conducive of good. They do not 
 mitigate the depression, but rather augment it (p. 32). 
 If the patient complains about uneasiness and anxiety, a 
 few comforting words may be said to him, but nothing 
 more should be done. 
 
 Likewise in morbid exaltation it is entirely wrong 
 to attempt to depress the mood of the patient artificially. 
 
142 PSYCHE 
 
 At best an outburst of anger is produced (p. 35). The 
 patient must not be directly contradicted; on the other 
 hand, it is not necessary to yield to all his whims. To 
 refuse the wishes of maniacal patients without direct 
 contradiction the peculiar ^'tractability" of the maniacs 
 is resorted to with great advantage (pp. 86, 167, 169). 
 
 Delusions. The management of delusions is sim- 
 ilar to that of morbid mood. Laymen often think they 
 can be overcome without difficulty. When, for instance, 
 a patient wails about the death of a dear friend, who is 
 still living, it is very easy, according to laymen's notions, 
 to do away with this delusion by bringing the friend face 
 to face with the patient. But the delusion will persist 
 nevertheless. The patient will now complain just this 
 is his great misfortune that some scoundrel tries to per- 
 sonify his dear friend. There remains, therefore, noth- 
 ing else to do but to try to allay somewhat the delusion, 
 e. g., to say to the patient he is sick now, when he will 
 be well again, everything will be in perfect order. 
 
 Formerly the attempt was sometimes made to sup- 
 press delusions of grandeur forcibly by cold douches and 
 other such harsh measures. But nothing was gained 
 thereby except that the patient now simulated, not dar- 
 ing to give expression to his delusions which he still har- 
 bored just as strongly as before. 
 
 Morbid Activity of the Will. Some patients 
 carry out so few volitional movements that they are un- 
 able even to take food handed to them. Such patients 
 must not be left sitting or lying, motionless for hours and 
 days, but psychical and mechanical stimuli must be em- 
 ployed. Usually little is attained by the former. To 
 admonish a stuporous patient to move about is like tell- 
 ing a person with fractures of both legs to walk. Words 
 
THERAPY OF INSANITY 143 
 
 are futile in such cases, but other effective measures must 
 be used, such as massage and passive exercises. 
 
 The management of patients controlled by irresist- 
 ible motor impulses and intent upon destroying every- 
 thing within reach is very difficult. It is evident that 
 they cannot be permitted to do as they please. Formerly 
 they were restrained mechanically by means of the strait- 
 jacket. Nowadays the treatment is not so harsh. In 
 the favorable season of the year they may be permitted 
 to move about in the open air. When the weather is too 
 cold or too hot, or otherwise unfavorable to keep them 
 out of doors, they must be isolated. To preclude tear- 
 ing of the clothes, they are made of firm material, as 
 English leather, which is also washable. For patients 
 of great strength still stronger material, as sailing 
 canvass, must be used. To prevent the patients from 
 undressing themselves, buttons have been constructed 
 which they can neither open nor tear off. The manu- 
 facture of foot-wear adapted for such patients also offers 
 great difficulties. 
 
 Refusal of Food. Some patients refuse to take 
 nourishment. If the reason for this is a diminution of 
 the volitional activity to such an extent that the patients 
 are unable to carry out any movement whatsoever, as in 
 stupor, artificial feeding ought not to be deferred very 
 long. It should be begun early and not postponed until 
 the patients are nearly exhausted through starvation. 
 But with melancholies who think themselves unworthy 
 of nourishment, or with patients who imagine their food 
 to be poisoned, artificial feeding may be deferred for 
 some time, especially since by means of certain devices 
 the patients can be induced to take some food. Such 
 patients, without being malingerers, eat in secret when- 
 
144 PSYCHE 
 
 ever possible. Melancholies declining to take food on 
 account of delusions of self -depreciation eat something 
 that appears discarded, believing it to be of no use for 
 anyone more worthy of nourishment than they are. 
 They do not take food handed to them in the proper 
 manner, but they consume that which has been left over 
 by others. Eating secretly is, therefore, not incompati- 
 ble with delusions which entail refusal of food. Patients 
 afraid of poison eat food destined for others. The re- 
 sistance to taking nourishment may sometimes be over- 
 come by offering to the patients their favorite dishes. 
 There remain, however, some patients who, induced by 
 delusions, would rather starve to death than take food. 
 In such cases artificial feeding should be delayed for a 
 while, but as soon as the slightest symptoms of inanition 
 appear, it must be carried out by means of the stomach 
 tube introduced through the mouth or the nose. 
 
 Insomnia. Almost every patient in the initial stage 
 of a psychosis suffers from sleeplessness. It can be com- 
 bated by drugs, but they are injurious. The assertion 
 may unreservedly be made that recovery from a psy- 
 chosis ensues so much sooner, the less hypnotics have 
 been used. For this reason insomnia ought not to be 
 treated directly, for a time at least. But when the 
 strength of the patient does not suffice to stand the ex- 
 hausting effects of sleeplessness, hypnotics are indicated. 
 An effective remedy is chloral hydrate. It should not 
 be given in larger doses than two grams. It must be 
 employed with great caution in the old and in those 
 affected with heart disease. Patients who refuse to take 
 any internal remedy may be given morphine hypoder- 
 mically. A convenient hypnotic, free from danger, is 
 
THERAPY OF INSANITY 145 
 
 paraldehyde which may be given in doses of 5 to 6 grams. 
 Sulfonal is dangerous and of Httle effect. 
 
 Suicide. Special attention must be paid to the sui- 
 cidal inclinations of the insane. To prevent suicide the 
 windows of the wards must be secured by gratings with 
 interspaces not wider than the smallest diameter of the 
 skull of an adult. Constant watching is necessary. In 
 the night several watchers should alternate. They 
 should be kept under strict supervision by a night watch- 
 man's apparatus furnished with all possible safeguards 
 against deception. 
 
 In suicidal attempts cutting and stabbing instru- 
 ments are not the most dangerous. Much more to be 
 feared is the attempt at hanging. It can be carried out 
 on any door latch, on any nail in the wall. A noose is 
 easily made out of a towel or handkerchief. Death fol- 
 lows quite rapidly. After cutting or stabbing, however, 
 the patients can often be saved even after a considerable 
 interval. Very dangerous is also the attempt at strangu- 
 lation, the patient constricting his throat with a cloth. 
 The rattling noise in the respiratory tract, commencing 
 with the ensuing dyspnoea, may be heard and attract the 
 attention of the attendants. Sometimes the patient's life 
 is saved by a relaxing of the pressure of the cloth when 
 his strength begins to fail. He may elude this by mak- 
 ing a knot and pulling it through a loop whereby a loos- 
 ening of the improvised string is prevented. He then 
 loses consciousness after a short time and death follows 
 rapidly. All these suicidal attempts can be frustrated 
 only by constant and careful watching. 
 
 Deficient Deglutition. Especially in paretics 
 deglutition is often impaired. They cannot swallow the 
 food properly and aspirate something of it into the larynx 
 
146 PSYCHE 
 
 or trachea. Such an incident requires immediate help be- 
 cause of the danger of suffocation. The physician hur- 
 riedly called to a case of foreign body in the respira- 
 tory tract may find the patient already unconscious, 
 cyanotic, pulseless. He must at once examine the air 
 passages. As soon as he succeeds to remove the foreign 
 body, life may return. There is hope of saving the pa- 
 tient's life as long as he is still cyanotic, and the lower 
 jaw is still firmly pressed against the upper one. The 
 greater the difficulty of removing the jaws from one an- 
 other, the more there is prospect of restoring the life of 
 the patient. For shortly before death the jaws are 
 tightly closed. Soon after death they become relaxed. 
 Much later, when rigor mortis has set in, the maxillary 
 muscles become again contracted. The physician must 
 force apart the jaws and reach down into the air pas- 
 sages as far as the vocal cords. Sometimes the foreign 
 body remains sticking in the oesophagus. H this be the 
 case, the foreign body must be pushed down further into 
 the stomach. Besides, the danger caused by a foreign 
 body in the oesophagus is not very great. At any rate 
 the physician must preserve his presence of mind and act 
 decidedly and quickly. 
 
 A patient may swallow something that injures the 
 oesophagus, for instance, a rough stone. As a conse- 
 quence food is regurgitated, although the foreign body 
 is not wedged any more in the oesophagus. An oeso- 
 phageal sound must be passed, li no resistance is en- 
 countered, the regurgitation, sometimes persisting for 
 several days, is merely caused by the wound in the oeso- 
 phageal mucous membrane. 
 
 Wounds of the Skin. Phlegmons, erysipelas, decu- 
 bitus, etc., must be prevented by paying careful attention 
 
THERAPY OF INSANITY 147 
 
 to the slightest lesions of the skin, especially in such 
 patients who are inclined to injure themselves. 
 
 Chapter LXVIII. 
 HYPNOTISM IN THE TREATMENT OF INSANITY. 
 
 Hypnotism is founded on suggestion, i. e., on the 
 possibility of introducing ideas from an outer source into 
 the train of thoughts of the hypnotizable subject. Sug- 
 gestion plays an important part in many affairs. The 
 art of persuasion is based on suggestion. In instruction 
 and education suggestion is made use of in manifold 
 ways. Since hypnotism has been recognized to depend 
 merely on suggestion, the former artifices of producing 
 the hypnotic sleep, as by stroking or by making the sub- 
 ject stare unremittingly at a brilliant object, etc., have 
 been abandoned. The hypnotic sleep can be brought 
 about simply by telling the individual to be hypno- 
 tized that he will soon fall asleep. The hypnotic sleep, 
 no matter in which way produced, renders suggestion 
 still more easy. Great hopes had been built upon hyp- 
 notism in the treatment of the insane. Unfortunately 
 the results of hypnotic treatment of insanity have proved 
 disappointing. Delusions, feelings of anxiety, depres- 
 sion, refusal of food, morbid volitional activity, etc., are 
 not influenced by hypnotism'. 
 
PART V 
 
 SPECIAL PATHOLOGY OF 
 INSANITY 
 
Chapter LXIX. 
 
 CLASSIFICATION OF THE PSYCHOSES. 
 
 In the classification of the psychoses pathologic 
 anatomy does not offer any clue to be followed. For 
 very little is known of the pathologic anatomy of in- 
 sanity. To arrange the manifold and intricate pictures 
 under which the psychoses present themselves into a 
 somewhat practicable system only the symptoms and 
 etiology of insanity are available. With regard to the 
 symptoms two classes of clinical entities of insanity may 
 be distinguished. 
 
 I. Mental disease commencing after the early 
 stages of the general development of the organism, the 
 patient having been sound in foetal life and in early 
 childhhod. 
 
 II. Mental diseases dating from earliest childhood 
 and attributable to arrest of development or to other 
 disturbances in foetal life or in early childhood. 
 
 To the first class belong the following clinical pic- 
 tures : 
 
 1. Melancholia and Stupor. 
 
 2. Mania. 
 
 3. Hallucinatory Insanity. 
 
 4. Primary Insanity or Paranoia. 
 
 5. Secondary Insanity. 
 
 6. Delirium. 
 
 7. Secondary Dementia, Secondary Feebleminded- 
 ness. 
 
152 
 
 PSYCHE 
 
 8. Primary Mental Weakness, Primary Curable 
 Dementia. 
 
 The second class comprises the following psychoses : 
 
 1. Idiocy. 
 
 2. Cretinism. 
 
 Idiocy appears in severe and mild forms. The latter 
 may be designated as imbecility. 
 
 Certain forms of one-sided mental weakness are in- 
 cluded in imbecility : 
 
 a. Moral Insanity, Moral Idiocy. 
 
 b. Querulous Insanity, Morbid Litigiousness. 
 
 c. Originary Insanity. 
 
 d. Contrary Sexual Feeling. 
 
 Considering the insane diatheses and etiology we 
 may distinguish the following forms of insanity : 
 
 I. Hereditary Predisposition to Insanity, Hered- 
 itary Insanity, 
 
 Hysterical Insanity. 
 
 Phrenasthenia, Psychasthenia, 
 
 Dementia Praecox, 
 
 Recurrent Insanity, Manic-depressive Insanity. 
 
 Epileptic Insanity, 
 
 Insanity of General Paresis, 
 
 Toxic Insanity, Alcoholic Insanity, 
 
 Traumatic Insanity, 
 
 Insanity in Organic Brain Diseases. 
 
 Delirium Acutum. 
 
 Senile Insanity. 
 There are many other classifications of insanity, 
 but no one has received general acceptance. 
 
 9 
 
 lO 
 
 II 
 
 12 
 
SPECIAL PATHOLOGY 153 
 
 Chapter LXX. 
 PSYCHOSES AND AGE OF PATIENT. 
 
 Certain psychoses occur most frequently at a certain 
 period of life. Cretinism and idiocy are observed chiefly 
 in childhood. Being permanent states they persist also in 
 adult life. Phrenasthenia, hysterical insanity, dementia 
 praecox, recurrent insanity prevail at the periods of 
 puberty and adolescence. In the age of maturity all 
 forms of insanity are met with, particularly paranoia, 
 general paresis, traumatic and toxic insanities. In and 
 after the climacterium melancholia is very frequent, and 
 senile insanity belongs to old age. 
 
SECTION I. 
 
 MENTAL DISEASES COMMENCING AFTER 
 
 THE EARLY STAGES OF THE GENERAL 
 
 DEVELOPMENT OF THE ORGANISM 
 
 Chapter LXXI. 
 MELANCHOLIA. 
 
 Symptom-complex. A characteristic complex of 
 symptoms constitutes the cHnical picture of melanchoHa 
 which is based on different causes, as intoxication, gen- 
 eral paresis, senility, etc. Its chief features are the fol- 
 lowing: The mood is morbidly depressed. The idea- 
 tional process is retarded, the memory weakened. The 
 patient labors under delusions of self-depreciation 
 (p. 57), and has sometimes hallucinations and illusions. 
 The frequency of the volitional manifestations is dimin- 
 ished, the energy lessened. The vegetative processes are 
 reduced. Sometimes the patient is suddenly seized with 
 attacks of anxiety and fear. During such spells the pic- 
 ture is somewhat different from the one just sketched; 
 the energy, for instance, is greatly increased (pp. 2^^, 34). 
 
 Clinical Picture. The patient has a sad expression 
 on his countenance and complains of feeling ill at ease. 
 He believes to be irretrievably lost in this world as well 
 as in the hereafter. He wishes for his death, but not as 
 a salvation; for he thinks everlasting perdition is allotted 
 to him. Sometimes this depressive state becomes in- 
 creased to an intense emotion of anxiety and fear. The 
 
SPECIAL PATHOLOGY 155 
 
 energy is then augmented. The patient runs about, rest- 
 less and agitated, cries and laments aloud, unwilling to 
 listen to any words of appeasement and consolation — 
 melancholia agitata. That the depression of mood, the 
 most important and most conspicuous symptom of melan- 
 choilia, is of morbid nature can easily be recognized. It 
 cannot be influenced in the least by persuasion and con- 
 solation, the reasons adduced by the patient to explain 
 it are entirely insufficient, and time has no mitigating 
 effect on it so that it persists with undiminished intensity 
 for weeks and months (Ch. 13, p. 31). 
 
 The ideational process is markedly retarded. It is 
 laborious for the patient to answer simple questions. He 
 is himself conscious of the great poverty of his ideas and 
 of the impairment of his memory. Fluctuations occur 
 in this condition in the course of the same day so that the 
 memory is less affected at some hours than at others. 
 
 The delusions of the melancholic patient are quite 
 characteristic. He imagines himself to be despised, exe- 
 crated, persecuted, and often gives utterance to his im- 
 agination. For the correct interpretation of these delu- 
 sions we must bear in mind that the patient himself 
 believes to deserve the contempt and persecution he main- 
 tains to be exposed to, that his self plays a role laden 
 with guilt and sin (Ch. 28, p. 57). He tries to explain 
 his delusions by some reason or other. Hallucinations 
 and illusions in several senses help to strengthen the delu- 
 sions, but in the main the latter are the outcome of the 
 morbid mood. 
 
 The frequency of the volitional manifestations is 
 diminished when attacks of anxiety and fear are not 
 present. The patient is quiet, speaks seldom, slowly, and 
 with a low voice, makes but hesitating movements with 
 
156 PSYCHE 
 
 little expense of power. His energy is lessened. He does 
 not make an effort to move from his place, not even to 
 relieve nature, and takes no nourishment or eats but 
 slowly and reluctantly. In an attack of anxiety, how- 
 ever, the energy may be so much increased that he is apt 
 to commit murder or suicide. 
 
 The vegetative processes are considerably reduced. 
 Sleep, appetite, digestion, and assimilation of food are 
 impaired. The blood circulation is sluggish, the tem- 
 perature of the body is somewhat lowered. The strength 
 of tHe patient decreases. Here and there oedema is no- 
 ticeable, especially on the lower extremities. The skin 
 presents a cyanotic appearance. Graying of the hair 
 occurs sometimes. It may be only temporary, the hair 
 assuming its previous color when recovery takes place. 
 
 Differential Diagnosis. Melancholia may be con- 
 founded with primary dementia. Severe acute diseases 
 sometimes result in great mental exhaustion representing 
 a complex of symptoms which is very similar to that of 
 melancholia and is designated as primary dementia (p 
 192). This psychosis lacks the characteristic depression 
 of melancholia, the patient being rather in an indifferent 
 than in a sad mood. The characteristic delusions of self- 
 depreciation are also missing in primary dementia. 
 Finally, the immediately preceding exciting cause, which 
 is either a grave infectious disease or excessive loss of 
 blood, furnishes a differentiating point for primary 
 dementia. 
 
 Melancholia and primary insanity or paranoia differ 
 from one another by the character of the delusions. In 
 melancholia ideas of self -depreciation, the consciousness 
 of guilt and sin, oppress the patient; in paranoia delu- 
 sions of grievance prevail, the patient believing himself 
 
SPECIAL PATHOLOGY 157 
 
 to be wronged without deserving it in the least (Ch. 28, 
 
 PP- 57-58). 
 
 Hallucinatory insanity resembles melancholia when 
 the contents of the hallucinations are of a disagreeable, 
 painful nature and, therefore, productive of a sad mood. 
 But in hallucinatory insanity the mood changes fre- 
 quently, conforming itself to the hallucinations present at 
 the moment, while the depression of melancholia is rather 
 uniform and steady. 
 
 Those cases of delirium which resemble melancholia 
 differ from it usually by the presence of fever. This dif- 
 ferentiating sign is the more reliable as a melancholic 
 patient falling ill with a feverish disease becomes free 
 from his melancholia. Besides, the usual causative factor 
 of delirium, i. e., intoxication, is, as a rule, demonstrable. 
 
 An epileptic patient in a sad mood may be taken 
 for a melancholic. But this mistake will occur only 
 when it is not known that the patient is epileptic. The 
 psychic equivalents (p. 243-244) of the epileptic attacks 
 offer many differentiating symptoms. 
 
 Therapy. The treatment of melancholia is sympto- 
 matic. Suicide is to be obviated by careful watching 
 which is especially necessary in the beginning of the psy- 
 chosis. Particular precaution is required during the emo- 
 tional attacks of fear because the energy of the patient 
 is then very much increased and he displays great rage 
 against himself and others. These attacks occur chiefly 
 in patients who present a very quiet appearance, and at 
 times manifest great considerateness. 
 
 Melancholies often refuse food, owing to their delu- 
 sions of self -depreciation, or because their feelings of 
 anxiety are increased when their stomach is filled. In 
 such cases the patients have to be fed artificially. But 
 
158 PSYCHE 
 
 even when the patients can be induced to take much 
 nourishment, the state of their general nutrition remains 
 poor because digestion and assimilation are impaired, due 
 to certain processes obtaining in the central nervous sys- 
 tem. Tlie patients should, therefore, not be forced to 
 eat more than is just necessary. Through certain devices 
 melancholies refusing food may be influenced to take 
 some nourishment (p. 144). If their refusal of food is 
 founded upon delusions of self -depreciation, upon the 
 idea of not deserving nourishment, they eat something 
 that appears discarded, or that others have left over. 
 
 If a melancholic patient refusing food is allowed to 
 hunger, he does not die of starvation, but he may be- 
 come so weak that a slight intercurrent disease may prove 
 fatal. 
 
 It is entirely useless to seek to disuade a melancholic 
 patient from his delusions. His condition may even be 
 made worse by such efforts (pp. 32, 141). 
 
 It is advisable to keep melancholies in bed for some 
 time to spare their strength by low^ering the expenditure 
 of bodily heat. But this rest cure must not be exagger- 
 ated, as weakness of the heart is apt to result from lack 
 of muscular activity. Oedema occurring in melancholies 
 is to be treated by furthering the blood circulation, as by 
 warm baths, by massage, by leading the patients up and 
 down, or by other muscular exercises. 
 
 The agitation of melancholic patients in emotional 
 attacks of anxiety and fear may be somewhat mitigated 
 by protracted warm baths and by medicinal sedatives. 
 In general, however, medicines should be used as little 
 as possible. For the prospect of recovery is so much 
 better, and convalescence comes so much sooner, the 
 less the brain has been influenced by drugs (p. 144). 
 
SPECIAL PATHOLOGY 159 
 
 Chapter LXXIL 
 STUPOR. 
 
 Stupor was formerly considered as a form of melan- 
 cholia. But although it frequently develops from melan- 
 cholia, it must not be identified with it. For the chief 
 symptoms of melancholia are missing in stupor. There 
 is neither depression of mood nor excitative anxiety in 
 stupor, but constant indolence without any emotional agi- 
 tation (Ch. 17, pp. 36, 37). At times stuporous patients 
 appear to be excited, a certain affective state prevailing in 
 which they create the impression of being fascinated, 
 spellbound. They fall into ecstasy and remain in this 
 state for hours and days without the slightest fluctua- 
 tion or alteration of emotional attitude, the mind all the 
 while being absorbed by a dominant idea. In severe 
 stupor no form of excitement whatsoever is noticeable. 
 
 The ideational process is at a standstill or a single 
 idea, the dominant idea, forms the^ whole contents of the 
 consciousness. Manifestations of the will are entirely 
 lacking. The patient remains motionless for hours and 
 days. Even the reflex movements are absent or dimin- 
 ished. The irritation by the atmosphere, ordinarily caus- 
 ing movements of the eyelids, has no effect in stupor. 
 The eyelids hardly respond by a reflex movement to an 
 irritation so strong as to produce tears. The patient 
 does not swallow his saliva and is frequently slavering. 
 The urine is not evacuated so that the bladder is usually 
 overfilled. The extremities remain in one and the same 
 position for hours and days, although such position may 
 be very uncomfortable or even painful. The peculiar 
 rigidity of the muscles in such conditions has been desig- 
 
i6o PSYCHE 
 
 nated as flexibilitas cerea. The vegetative processes are 
 as sluggish as the voHtional activity. 
 
 Consciousness and orientation are considerably im- 
 paired in stuporous patients. 
 
 The condition of the patient sometimes changes un- 
 expectedly: All of a sudden he is aroused from his 
 lethargic state and regains consciousness to the extent of 
 being able to appreciate his circumstances. The lethargic 
 condition may also pass suddenly into maniacal excite- 
 ment. These attacks are not of long duration and return 
 to the former lethargy. 
 
 A certain stupor occurs which does not correspond 
 to the above picture. It is founded on a terrifying hallu- 
 cination. The patient remains rigid in the posture occu- 
 pied at the moment of the dreadful hallucination, and 
 does not stir for fear that the slightest movement may 
 prove disastrous. 
 
 Differential Diagnosis. Stupor resembles primary 
 curable dementia which is also characterized chiefly by 
 barrenness of the ideational and affective spheres (Ch. 
 1 7, pp. 36, 2)7)' But in stupor the poverty of ideas is often 
 due to the persistence and predominance of one idea pre- 
 venting other ideas from arising in the field of conscious- 
 ness. The reflex movements are not impaired in primary 
 dementia, but greatly diminished in stupor. Patients suf- 
 fering from primary dementia never show the peculiar 
 rigidity of the muscles — flexibilitas cerea — which is 
 often observed in stupor. They take sufficient nourish- 
 ment and have no disturbance of the bladder. Finally, 
 in primary dementia we learn through the anamnesis 
 that the psychosis has been preceded by excessive loss of 
 blood or a severe infectious disease. 
 
 Secondary dementia (p. 189) following upon an 
 
SPECIAL PATHOLOGY i6i 
 
 acute psychosis may sometimes be taken for stupor. For 
 the ideational sphere may have been greatly devastated 
 by the preceding acute mental disorder. But although, 
 in some instances, secondarily demented patients produce 
 very few ideas, their mental dullness never reaches the 
 extreme degrees met with in stupor. In secondary de- 
 mentia the reflexes are not diminished, sleep and appetite 
 are not impaired, and rigidity of the muscles is lacking. 
 The condition of the patient in secondary dementia re- 
 mains stationary and is not interrupted by sudden tran- 
 sitory changes such as. occur in stupor. Finally, in sec- 
 ondary dementia the anamnesis shows that an acute 
 mental disease has preceded. 
 
 Therapy. To try to exert a psychical influence on 
 a stuporous patient is a useless undertaking. The result 
 obtained by mechanical manipulations is very slight also. 
 Special attention is to be paid to the nutrition of the 
 patient. The attending physician must know what and 
 how much the patient eats. If the patient does take food 
 handed to him, the nurses may be permitted to feed him. 
 If however he does not open his mouth or does not 
 swallow the food forced into his mouth, artificial feed- 
 ing must be begun early and carried out by the physician 
 himself. 
 
 Stuporous patients who remain sitting on one spot, 
 motionless for so long a time that their lower extremities 
 become swollen, should, if possible, be led up and down 
 the room, or else be put to bed and massaged. Bandag- 
 ing the legs is also useful. 
 
 The attending physician should not rely upon the 
 reports of the attendants regarding the functions of blad- 
 der and rectum, but should examine these organs from 
 time to time and see to it that they are properly evacu- 
 
i62 PSYCHE 
 
 ated. At a digital examination of the rectum, he will 
 sometimes, especially in female patients, find it filled 
 with an enormous quantity of faecal masses even when 
 the patient is reported to have diarrhoea. 
 
 Stuporous patients are very liable to be harmed by 
 fluctuations of the atmospheric temperature. ■ In cold 
 weather they readily acquire chilblains, and exposed to 
 the direct sunrays they develop symptoms of insolation. 
 They must, therefore, be warmly clad in winter and kept 
 away from the direct sun rays in hot weather. 
 
 Stuporous patients should not be left alone with 
 other patients. For they may suddenly be seized with 
 an attack of great excitement in which they are apt to 
 commit dangerous acts. 
 
 Termination. Stupor may end in recovery. It may 
 also pass without an intermediary stage into a state of 
 maniacal excitement, the clinical picture of stupor being 
 henceforth substituted by that of mania. 
 
 It is remarkable that stupor disappears when an 
 acute infectious disease, as typhoid fever, intervenes. The 
 freedom from the stupor, however, lasts only as long as 
 the infectious disease does; when the latter ceases, the 
 stupor reappears. 
 
 Chapter LXXIII. 
 
 MANIA. 
 
 Remark. The clinical picture of the mental disorder called 
 mania consists of a well defined complex of symptoms. Morbid 
 exaltation of the mood is its predominating feature, and from this 
 all other symptoms are derived. A patient presenting this clinical 
 picture is called a maniac. The word maniac (manic, maniacal), in 
 this whole treatise, is used exclusively in this sense, but not in 
 the meaning violently insane, which it usually has in every-day 
 
SPECIAL PATHOLOGY 163 
 
 language. Not every excited insane patient is a maniac. Melan- 
 cholies and patients suffering from other forms of insanity, for 
 instance, hallucinatory insanity, may be as restless, agitated, and 
 violent as a maniac. The term manic-depressive insanity for a 
 certain psychosis (pp. 235-236) is not very appropriately selected. 
 For the two component parts of the adjective are complete opposites. 
 And yet when they are used in conjunction to characterize a patient, 
 the impression is created that he is suffering at the very same time 
 from morbid exaltation and morbid depression. In a strict sense 
 this is impossible, nor is it at all the case in manic-depressive in- 
 sanity. For setting aside the so-called mixed states (p. 237), the 
 theory of which is still far from being firmly established (p. 239), 
 we find that in manic-depressive insanity the patients present symp- 
 toms of exaltation (manic) at some periods and those of depression 
 at other periods, but not both at the same time. This psychosis 
 has been called periodic (circular) insanity — recurrent insanity — 
 which term is certainly less misleading than the designation manic- 
 depressive insanity. It may not be out of place to add here that 
 some psychiatrical writings are greatly lacking in clearness, owing 
 to the intermingling of the popular and psychiatrical significations 
 of the word maniac (manic). 
 
 Symptom-complex. Morbid exaltation of the 
 mood is the characteristic symptom of mania. Now 
 and then the patient falls into an angr}^ mood, but it is 
 merely a transitory reaction to resistance and difficulties 
 put in his way and passes away quickly. The ideational 
 process is accelerated, the memory is facilitated. Hallu- 
 cinations occur in one or in several senses. Delusions of 
 grandeur (Ch. 28, p. 57) are, as a rule, present. The 
 frequency of the volitional manifestations is increased 
 (Ch. 37, p. 77). The energy is augmented with regard 
 to the application of great muscular power, but dimin- 
 ished as to purposeful and persistent action (Ch. 41, 
 p. 83). The vegetative processes are enhanced, due to 
 certain causes obtaining in the central nervous system. 
 Appetite and digestion are excellent and food is assimi- 
 lated very well. Owing to his great exertions the patient 
 
1 64 PSYCHE 
 
 loses weight and strength, but much less than would nor- 
 mally be the case with the same exertions. Sleep is 
 reduced a good deal. 
 
 Clinical Picture. The patient is constantly in a 
 rosy humor. He maintains to be in excellent circum- 
 stances and to enjoy the best of health. On his coun- 
 tenance rests a happy expression, his eyes are glistening 
 with joy. The reasons adduced by the patient to explain 
 his great cheerfulness are insufficient, or there are even 
 causes present which ought to produce sadness. The ex- 
 alted mood is, therefore, of morbid nature (Ch. 15, p. 
 34). If the attempt is made to pull the patient down 
 from his heaven of bliss, he has but a smile of pity for 
 the bearer of the ill tidings, or gets angry at him. The 
 cheerful mood lasts exceedingly long, which is another 
 criterion for its being morbid (p. 35). It happens that 
 a maniacal patient weeps. But this is already a sign of 
 approaching convalescence, indicating that the patient 
 now and then is in a normal affective state and recognizes 
 his misery (pp. 128, 129). Weeping does, therefore, not 
 exclude mania, but is an indication that the end of the 
 mental malady is not far off. 
 
 The acceleration of the ideational process is recog- 
 nized chiefly by the patient's manner of talk. He is very 
 loquacious. In conversation he soon gains the upper 
 hand, speaks about things never intended to be drawn 
 into the conversation, and wanders quickly from one sub- 
 ject to another. It appears as though one idea would 
 drive the other away — flight of ideas — (pp. 36, 42). 
 The patient shouts, sings, and laughs, thus interrupting 
 at times his exuberant talk. In aggravated cases the 
 acceleration of the ideational process may be so great 
 that the apparatus of speech becomes inadequate to fol- 
 
SPECIAL PATHOLOGY 165 
 
 low and express the ideas rapidly rushing one after an- 
 other. Only fragments of sentences, single incoherent 
 and incomprehensible words, are then uttered. The 
 superabundance of ideas is manifested also by the pa- 
 tient's ability to construct rhymes. 
 
 The accelerated course of ideas brings about an im- 
 provement of memory. The tension in the nervous ele- 
 ments and paths is raised so that their resistance is more 
 easily overcome (Ch. 8, p. 19). The reproduction of 
 memory images by way of the association paths is thus 
 facilitated. The patient believes to be clever and posr 
 sesses indeed a certain wittiness. When the maniacal 
 excitement is slight, a layman, easily misled, may regard 
 the patient merely as a talkative, merry person. 
 
 The patient is laboring under delusions of grandeur. 
 He interprets everything to his favor, overestimates his 
 powers, and underestimates difficulties and obstacles. He 
 deals with persons whom, when he was sane, he would 
 accost with the greatest reverence, in the most familiar 
 way as though they were his equals. When hallucina- 
 tions supervene or when the maniacal excitement is great, 
 the delusions are more pronounced. The patient then 
 believes to be possessed of great wealth, to be an emi- 
 nent personage who, by his own unlimited power, will 
 bring order and rule into this wicked world. The delu- 
 sions either bear the mark of the irrational and ridiculous, 
 thus being absurd delusions of grandeur (pp. 55, 56) ; or 
 else they are explained by the patient in a fairly plausible 
 way. Whether one or the other is the case depends upon 
 the basis of the psychosis. In mania of general paresis 
 the delusions are almost always characterized by absur- 
 dity. The patient asserts he possesses billions, is the 
 emperor of China or some divinity. He often contra- 
 
1 66 PSYCHE 
 
 diets himself without being sensible to the contradiction. 
 In mania of periodic insanity, hereditary insanity, senile 
 insanity, however, fairly good reasons are adduced by 
 the patient for his delusions of grandeur (pp. 55, 56). 
 
 Hallucinations are rarely wanting in mania. They 
 are interpreted by the patient to his advantage. They 
 confirm what he believes and wishes. If they do not, 
 he reacts towards them with outbursts of anger. 
 
 The increased frequency of volitional manifestations 
 is expressed by a constant impulse for movement. The 
 movements are carried out for their own sake and have 
 no special aim. In the open air the patient rambles about, 
 runs, jumps. When he is isolated, he tugs at his clothes, 
 tears them, handles his excretions, smearing the walls 
 and other objects with them. Especially female patients 
 wallow on the floor, pluck at their hair and dirty it with 
 their excrements. These manipulations have been called 
 symptoms of isolation. As a rule, the maniacs are hoarse 
 after their excitement has lasted a few days, owing to 
 the constant talking, singing, shouting. 
 
 The augmentation of the energy of force (p. 83) 
 is exhibited by an excess of power in all actions. The 
 movements of the patient are forceful, extravagant in 
 strength. In conversation he shouts. Requested not to 
 speak so loudly, he lowers his voice for a moment to 
 resume the former loud tone after a while. In writing 
 he makes powerful long strokes. It is interesting to 
 observe the handwritings of a paretic patient in the ma- 
 niacal and melancholic stages. They can be clearly dis- 
 tinguished, and thus the stage of the psychosis to which 
 each handwriting belongs can be established. It has been 
 maintained that patients in maniacal excitement are pos- 
 sessed of greater strength than they normally have, per- 
 
SPECIAL PATHOLOGY 167 
 
 haps due to certain processes obtaining in the central nerv- 
 ous system. But it is possible that the movements of 
 maniacs bear an excess of power because the considera- 
 tion does not enter their mind that they are liable to 
 derive harm from waste of strength (pp. 83-84). 
 
 With regard to persistent action, however, the 
 energy of the maniac is lessened. He is unable to con- 
 centrate his attention upon a subject and readily yields 
 to incidental impulses. Any intervening perception is 
 sufficient to divert him from what he had just intended 
 to do. By directing his attention to another object he 
 may be made to give up a design which he seemed to be 
 intent upon carrying out. This peculiarity of the maniac 
 brings about his '' tractahility" which is of great impor- 
 tance in the treatment (p. 86). In an outburst of vio- 
 lence necessitating great force to subdue the patient, one 
 can manage him without much difficulty by resorting to 
 the maniacal tractability. 
 
 As to the vegetative processes, sleep is reduced. 
 Nevertheless the strength of the patient remains fairly 
 well preserved. He does not look exhausted, although 
 he loses a little weight. The face appears ruddy, the 
 eyes glisten. This preservation of the patient's strength 
 notwithstanding excessive physical and mental exertion 
 is founded on certain causes which prevail in the central 
 nervous system. The patient eats much, digests and as- 
 similates the food very well. The fact that maniacs do 
 not become exhausted with all their great exertions is 
 very important for the distinction of malingerers from 
 patients. 
 
 Differential Diagnosis. The monomanias 
 
i68 PSYCHE 
 
 (pp. 88, 89), such as kleptomania, pyromania, phono- 
 mania*, etc., do not belong to mania proper at all. The 
 pyromaniacs are usually idiots (p. 199), the kleptomaniacs 
 are paretics, the phonomaniacs* are paranoiacs laboring 
 under certain delusions. At best nymphomania may be 
 brought into relation to maniacal excitement. Especially 
 female maniacs exhibit great sexual excitement, uttering 
 the most obscene exclamations relating to the sexual 
 activity. 
 
 Not every restless, boisterious patient is a maniac. 
 Melancholies in an emotional attack (p. 154) are also 
 restless and violent, but fear is the foundation of their 
 agitation, which excludes mania. 
 
 Course and Prognosis. Maniacs may be com- 
 pletely restored unless the basis of their mental disease is 
 unfavorable as is the case, for instance, in general par- 
 esis. The extent of the patient's agitation is irrelevant 
 as regards his recovery. 
 
 The maniacal excitement may pass into melancholia 
 as in hereditary insanity or periodic insanity. The change 
 occurs sometimes quite suddenly; in the course of one 
 night the clinical picture assumes an entirely different 
 aspect, so that the patient can hardly be recognized on 
 the following day. 
 
 During convalescence maniacal patients frequently 
 show a considerable abatement of strength. When the 
 causes prevailing in the central nervous system for the 
 enhancement of the vegetative processes have ceased 
 with the discontinuance of the psychopathological process, 
 the patients may pass into a state of great physical and 
 mental exhaustion as a result of the preceding exertions. 
 
 * The derivation of phonomania, phonomaniac, is explained in 
 the foot-note on p. 88. 
 
SPECIAL PATHOLOGY 169 
 
 The further prognosis is to be given with great caution. 
 The assumption must not be made forthwith that the 
 acute mental disorder has ended in permanent feeble- 
 mindedness. For a long time is necessary for some pa- 
 tients to recover from the enormous exertions they have 
 gone through during the maniacal excitement. It is, 
 however, possible that the mental weakness, noticeable 
 when the acute pathological process has ceased, remains 
 permanent, i. e., that the mania has terminated in sec- 
 ondary dementia, secondary feeble-mindedness. 
 
 Therapy. In the management of maniacal patients 
 their "tractability" (p. 167) affords valuable aid when 
 employed judiciously. No direct resistance must be 
 offered them, nor their desires flatly refused. By direct- 
 ing their attention to some other object they can be in- 
 duced to abandon their intentions. Care must be taken 
 that certain desires are not awakened in them. Danger- 
 ous instruments, objects of value, etc., must be kept out 
 of their sight. 
 
 It is necessary to see to it that the patients do not 
 become exhausted through overexertion. Exhaustion is 
 likely to occur especially in mania of senile insanity. 
 Sometimes artificial appeasement through hypnotics is 
 indicated to prevent exhaustion. In juvenile patients 
 exhaustion is not to be feared much, yet caution is re- 
 quired. For the patients are readily liable to contract 
 injuries through their agitated conduct, and injuries in 
 maniacs are very dif^cult to treat. For the same reason, 
 care must be taken that the patients do not swallow food 
 of extreme temperature or otherwise dangerous. They 
 must not be allowed to smoke, to drink in excess, etc. 
 
I/O PSYCHE 
 
 Chapter LXXIV. 
 HALLUCINATORY INSANITY. 
 
 The occurrence of a psychosis characterized 1)y 
 hallucinations as the chief feature has been called in ques- 
 tion. But there is a clinical entity of insanity in which 
 hallucinations form the primary and dominant symptom 
 giving rise to all the other psychopathic manifestations. 
 This mental disease may, therefore, be appropriately 
 designated as hallucinatory insanity. 
 
 Symptom-complex. The principal symptom of the 
 psychosis are hallucinations. They occur in one or in 
 several senses and determine the affective state (p. 14). 
 The latter show^s no primary disturbance, but is only sec- 
 ondarily changed ; exaltation, depression, or angry mood, 
 etc., prevails according to the character of the hallucina- 
 tions. The affective state, in turn, influences the course 
 of ideas accelerating or retarding it (Ch. 7, p. 18). The 
 memory is facilitated when the affective state is exalted, 
 and impeded w^hen it is depressed. The frequency of the 
 volitional manifestations is increased or diminished, de- 
 pending upon the affective state. The vegetative proc- 
 esses, too, are affected only secondarily. Appetite, diges- 
 tion, and assimilation may be disturbed or normal. Some 
 patients reject food and decline in strength, but to no 
 greater extent than a normal individual taking no nour- 
 ishment. When appetite and sleep are not disturbed, 
 the state of the general nutrition remains satisfactory. 
 
 Clinical Picture. The clinical picture of hallu- 
 cinatory insanity is very manifold. For it varies accord- 
 ing to whether the hallucinations take place frequently or 
 rarely, whether they are of agreeable or disagreeable 
 
SPECIAL PATHOLOGY 171 
 
 nature, and whether one or several senses are involved in 
 the hallucinations. 
 
 Some patients hallucinate very rarely. Thus in tak- 
 ing the anamnesis in a case of hallucinatory insanity we 
 may learn that some ten years ago the patient had "heard 
 a voice" and had not known what to make of this. Such 
 a patient is greatly perplexed by his hallucination, unable 
 to explain to himself the strange phenomenon, and is 
 afraid or ashamed to confide his experience to any one. 
 Such cases of hallucinatory insanity will remain doubt- 
 ful, for a long time at least, because the patients conceal 
 their hallucinations which worry them only once in a 
 great while. 
 
 It occurs that a person all of a suddent becomes 
 greatly agitated, frantic, and performs violent acts 
 which cause his commitment to an insane asylum. 
 Here he is perfectly quiet and composed and it is 
 impossible to notice anything abnormal in him. The 
 diagnosis transitory insanity should not be advanced 
 forthwith in such a case, for it does not explain 
 the case. But we should rather bear in mind that 
 the patient's strange behavior may have been due to 
 hallucinations which he is now unwilling to reveal. 
 Change of locality is also to be taken into consideration. 
 For hallucinating patients become free from their hallu- 
 cinations, for some time at least, when they are removed 
 from their accustomed surroundings. A prisoner, for 
 instance, is seized with hallucinatory insanity and com- 
 mits strange acts. Brought thereupon into the insane 
 asylum for observation, he shows a normal behavior. 
 Only after a long interval a change may again take place 
 in the conduct and character of the patient, proving him 
 to be insane and revealing the nature of the psychosis. 
 
172 PSYCHE 
 
 Hallucinatory insanity of this form is very commonly 
 designated as transitory insanity. 
 
 In another instance a patient is brought into the 
 asylum in a state of great confusion. He is very rest- 
 less, excited, violent, and covers his face and ears as 
 though to avoid seeing and hearing. He creates the im- 
 pression of being in delirium. In such cases it is also at 
 first impossible to obtain from the patients a proper ac- 
 count about their mental attitude, and hallucinatory in- 
 sanity can only be surmised. When the patients become 
 free from their hallucinations, their confusion and agi- 
 tation cease, and then it may be possible to establish that 
 they had been under the influence of hallucinations. 
 
 A third clinical picture of hallucinatory insanity is 
 manifested in the following way. The patient is con- 
 siderably excited once in a while, changes his domicile 
 several times without adequate reasons, and suddenly 
 performs a violent act which causes his commitment to 
 the insane asylum. Here he relates he has repeatedly 
 "heard" or ''seen" this and that and has been unable to 
 interpret his experiences, but now he understands every- 
 thing after the physician has explained to him that 
 all his troubles have been brought about by sense decep- 
 tions. 
 
 Again in another instance the patient makes re- 
 peated attempts at suicide, is depressed or agitated, tears 
 his clothes, refuses food, laments loudly that he will 
 soon be thrown into prison, executed, etc. His condition 
 would suggest the diagnosis melancholia (melancholia 
 agitata). Questioned on what he bases his fear of being 
 arrested, beheaded, he replies he has ''heard people say" 
 that he has committed a crime ; but these imputations do 
 not contain a particle of truth. Such an answer shows 
 
SPECIAL PATHOLOGY 173 
 
 that the patient is hallucinating, for it represents the 
 characteristic contents of a hallucination. 
 
 Other patients complain that they are continually 
 vexed by strange perceptions of hearing and sight. They 
 implore their friends and their physician to relieve them 
 from these intolerable sufferings. Suddenly their con- 
 dition is changed and they are entirely composed; they 
 are rid of their tormenting hallucinations for a day or 
 two. Then the same play is repeated. 
 
 Thus hallucinatory insanity presents widely differing 
 clinical pictures. The patients may be quiet, agitated, 
 violent, confused, desperate, intent upon suicide, waver- 
 ing, etc. 
 
 Differential Diagnosis. A hallucinating patient 
 may be taken for a maniac. But after a few days' ob- 
 servation it happens that the patient refuses food. The 
 diagnosis mania is then to be provided with a question 
 mark. It may, indeed, be the case that a maniac does not 
 take nourishment, because he does not find time to eat, as 
 it were, or because he is unable to carry out the movements 
 necessary for eating, due to flight of ideas. But if an 
 attendant helps him, steadying his hands and arms or 
 handing him the food, he takes it even with eagerness. 
 A hallucinating patient, however, will persist to refuse 
 food in spite of such help. 
 
 Paranoia is to be taken into consideration. If the 
 patient is excited, believing to be unjustly persecuted, 
 this delusion of grievance (Ch. 28, p. 57) may intimate 
 paranoia. But the hallucinating patient never exhibits 
 the peculiar tendency of drawing conclusions from his 
 perceptions as does the paranoiac; he would not see in 
 insignificant incidents proofs for his delusions, as would 
 the paranoiac. His judgment is still sound in this re- 
 
174 PSYCHE 
 
 spect. Besides, the paranoiac usually harbors at the 
 same time delusions of being furthered (Ch. 29, p. 58) 
 and tries to bring them in accord with his delusions of 
 being wronged, explaining the contradiction between 
 both and combining them into one system (systematized 
 delusions). The hallucinating patient does not think so 
 systematically with regard to his delusions. Moreover, 
 since hallucinations are caused by certain irritative states 
 of the brain cortex, their contents will not be stable, 
 but subject to frequent changes. While the paranoiac 
 is controlled by definite and comparatively lasting ideas, 
 the hallucinating patient's mental attitude is dependent 
 upon what he just happens to "hear" or "see." To-day 
 he may be in one frame of mind, to-morrow in another 
 one. 
 
 Hallucinatory insanity resembles melancholia when 
 the patient is in despair or excitative fear. But this sec- 
 ondary apprehensive anxiety of the hallucinating patient 
 is distinguished from the primary one of the melancholic 
 by the delusions present. In melancholia delusions of 
 self -depreciation are usually demonstrable. The patient 
 believes to deserve the persecutions he complains about. 
 This suppression of self-esteem is absent in the hallucin- 
 ating patient. He considers himself innocent. 
 
 Prognosis and Etiology. Hallucinatory insanity 
 may be followed by restitutio ad integrum, and this some- 
 times quite suddenly with the cessation of the hallucina- 
 tions. The mental disturbance lasts in some cases only a 
 few weeks. In other instances the hallucinations com- 
 mence slowly and persist for years. Some patients re- 
 main the prey of their hallucinations for ten years and 
 longer. But even after many years' duration complete 
 recovery may ensue. 
 
SPECIAL PATHOLOGY 175 
 
 Intoxication is frequently at the basis of hallucin- 
 atory insanity (morphine, cocaine). Sometimes sud- 
 den withdrawal of an accustomed stimulant furnishes 
 the etiological factor of the psychosis. The removal of 
 the intoxicating agent or careful administration of the 
 habitual excitant may restore the patient's health. Very 
 often trauma is the cause of hallucinatory insanity. In 
 such cases the hallucinations may disappear and the pa- 
 tient recover when the consequences of the concussion of 
 the brain have ceased. The prognosis of traumatic 
 hallucinatory insanity is, therefore, not unfavorable. Yet 
 it is to be given with caution since the hallucinations 
 may in any case persist for years. It also occurs in 
 traumatic hallucinatory insanity that after some time the 
 patient becomes free from his hallucinations and is en- 
 tirely normal for a long time, and then the mental dis- 
 order sets in again in its former intensity. 
 
 Therapy. In the treatment of hallucinatory in- 
 sanity it is necessary to bear in mind that a hallucinating 
 patient is entirely unreliable. He may be cheerful, quiet, 
 harmless to-day, despondent, violent, dangerous the next 
 day. The compelling force of the hallucinations is apt 
 to drive the patient into committing atrocious misdeeds. 
 Intelligent patients report that the hallucinations are 
 sometimes followed by irresistible impulses for certain 
 acts (Ch. 25, p. 52). The momentary suggestion of a 
 hallucination may thus instigate a crime. Hallucinating 
 patients, therefore, require careful watching. 
 
 When the cause of hallucinatory insanity, e. g., in- 
 toxication, abstinence, or trauma, has been established, the 
 attempt is to be made to remove the harmful conse- 
 quences of these etiological factors. 
 
176 PSYCHE 
 
 Chapter LXXV. 
 PRIMARY INSANITY, PARANOIA. 
 
 Symptom-complex. Primary insanity or paranoia, 
 unlike secondary insanity (p. i8i), develops during a 
 state of normal health. The mental disorder starts with 
 a peculiar affective state. The patient commences to be 
 constantly harrassed by an indefinable feeling of being 
 observed, of being the object of everybody's attention, 
 partly in a benevolent, partly in a malicious sense. He 
 feels ill at ease, his mental tranquillity is disturbed, be- 
 cause he imagines that all the people around him are 
 concerned about him. The ideational sphere shows noth- 
 ing remarkable as to the frequency of ideas arising in 
 consciousness, but is characterized by definite delusions, 
 by ideas of being furthered and wronged (pp. 55-59), 
 by ideas of furtherance and grievance. These two forms 
 of delusions are brought in accordance with each other, 
 and contradictions between them are explained with 
 some measure of plausibility (Ch. 29, p. 58). The delu- 
 sions are corroborated by hallucinations. The frequenc}- 
 of the volitional manifestations is not changed, or not 
 unusual. The energy dependent upon tlte delusions is 
 sometimes considerably increased (p. 85). In the vege- 
 tative sphere there is impairment of sleep, owing to great 
 excitability. The willingness to take nourishment is in- 
 fluenced by the delusions. Some patients eat normally, 
 others abstain from food. Within this complex of symp- 
 toms there are many forms of primary insanity. 
 
 Clinical Picture. In a state of fairly good health 
 the patient commences to feel uneasy. Everything around 
 him gives him the impression as though "something was 
 the matter." He is constantly annoyed by the thought 
 
SPECIAL PATHOLOGY 177 
 
 that he has mistaken his vocation, that he had been 
 destined to occupy a more important position in Hfe than 
 he does. This mood often arises quite suddenly. Many 
 a patient reports he had changed his domicile to avoid 
 certain annoyances. In the new place he had lived with 
 a tranquil mind for a long time. Incidentally somebody 
 looked at him in a strange manner, and from this mo- 
 ment his mental tranquillity was gone. After another 
 change of residence he had made a similar experience. 
 
 In the mood just outlined the patient is unable to 
 perceive things correctly and misinterprets circumstances 
 and occurrences. He attributes significance to everything 
 he sees and hears, although in reality it is of no impor- 
 tance and has no relation whatsoever to his person (pp. 
 74-75). In any newspaper article he reads reports that 
 concern him. The feeling of being a person about whom 
 people busy themselves a good deal, leads him to the belief 
 that he is a man of great importance. He argues after 
 this manner : 'T am a plain person, have never attempted 
 to force myself to the front: why do the people con- 
 stantly direct their attention toward me? There must 
 be something to it." In this way he arrives at certain 
 wrong notions, i. e., at delusions, even without the inter- 
 vention of hallucinations. The delusions become more 
 definite and pronounced when, after some time, hallu- 
 cinations supervene. The auditory hallucinations are 
 usually short, restricted to a few words, infinitives or 
 imperatives, as ''there he comes \" ''looks like the prince," 
 "favorite of the king," "to arrest," "run!" "shoot!" 
 "catch!" etc. 
 
 The hallucinations impart exactness to the patient's 
 delusions. From a certain exclamation he derives the 
 conviction that he is not descended from the man who 
 
178 PSYCHE 
 
 has passed for his father until now, but from a prince. 
 He beHeves to have a claim to the throne. Now he is 
 able to explain to himself why some time ago somebody 
 had gazed at him with a look portenting evil. This per- 
 son was a rival of his who had the intention to do away 
 with him by foul means in order to acquire the throne. 
 The patient tries to bring the events of his former life 
 into relation to his present ideas, to recall from his early 
 youth occurrences which, already at that time, pointed 
 to his future greatness, to his being descended from a 
 king, etc. — systematized delusions. It occurs to him that 
 his teacher had given him a picture with a crown on it, 
 that his mother had told him a story of a prince, that a 
 high personage had shaken hands with him and had 
 treated him very graciously, etc. All this intimated that 
 he was entitled to the throne. Now he wants to take a 
 decisive step toward the acquisition of the crown. He 
 changes his domicile and undertakes long journeys to 
 get out of the way of his adversaries and to be undis- 
 turbed in the pursuit of his aim. He even abandons his 
 vocation. Relatives and neighbors soon notice that he 
 has become irrational and irresponsible. Now and then 
 he makes threatening remarks against people whom he 
 imagines to be his enemies. In this stage the patient has 
 become a public danger, and his commitment to the in- 
 sane asylum takes place. Here he assures the physician 
 everything he has told him is absolutely true, although it 
 may sound rather incredible. 
 
 In some instances the delusions and through these 
 the whole clinical picture bear a religious character. The 
 patients imagine to have been selected by God to redeem 
 the wicked world and to be persecuted, therefore, by the 
 Evil One. Most forms of religious insanity belong to 
 
SPECIAL PATHOLOGY 179 
 
 paranoia. Formerly religious paranoia, in which divine 
 suggestions, demoniacal possession, belief in devilry, etc., 
 played a prominent part, was quite frequent. Nowadays 
 more modern delusions figure frequently in paranoia. 
 The patients believe to be chloroformed, electrized, hyp- 
 notized, to hear telephonicall}^ to receive messages by 
 wireless telegraphy, to see by means of X-rays, to soar 
 high above the clouds in a dirigible air-craft, etc. The 
 hallucinations and delusions in paranoia, the same as in 
 other psychoses, are modernized, as it were, the latest 
 invention being brought into play in their formation. 
 
 The delusions play the principal part in the clinical 
 picture of paranoia. They are well distinguished from 
 similar delusions of other psychoses. The paranoiacs 
 are not possessed by the consciousness of guilt and sin, 
 but believe to be innocent and regard their persecutors 
 as malicious persons who try to harm them for no just 
 cause. Their persecutory ideas are, therefore, delusions 
 of grievance. These often resemble the melancholic de- 
 lusions of self -depreciation. But there is a marked dif- 
 ference between both. In paranoia the patient's self- 
 esteem is not diminished in the least, but in melancholia 
 it is greatly lowered (Ch. 28, p. 57). 
 
 The paranoiic delusions of furtherance are similar 
 to delusions of grandeur. But the primarily insane pa- 
 tient does not have the feeling of being able to attain to 
 greatness through his own unlimited powers. He owes 
 all his present and prospective successes to his descent, 
 to the benevolence of His Majesty, of the Holy See, of 
 God, etc. He is therefore controlled by ideas of being 
 the object of favor and bounty. He cannot help being 
 destined for an excellent future. 
 
 Paranoiacs are often quick at repartee in solving 
 
i8o PSYCHE 
 
 contradictions prevailing between their delusions of fur- 
 therance and those of grievance. 
 
 Forensic Consideration. The delusions may in- 
 duce the paranoiacs to perform all kinds of offensive acts. 
 Some patients inflict injuries on themselves. Self -mutila- 
 tion of the genital organs, for instance, occurs in religious 
 paranoia. Other patients imagine that their strength is 
 being diverted from them, that life-blood and other vital 
 juices are withdrawn from their body. They drink, 
 therefore, their own urine, hoping to regain their vigor 
 through it. Another paranoiac conceives the notion that 
 the blood of a child or the testicles of a young boy will 
 render him invincible and invulnerable. This notion may 
 lead him to commit atrocities or murder. Driven by 
 delusions the paranoiacs make murderous attacks upon 
 people coming in their way. 60 to 70% of the assaults 
 upon kings, princes, and high dignitaries are due to prim- 
 ary insanity. The paranoiacs, therefore, come often into 
 conflict with the Penal Code. They frequently know 
 very well that their acts are criminal. They admit that 
 they had known it, and their sole defense is that they 
 had committed the crime in order that their cause might 
 become known to the public, and their adversaries be 
 severely punished. 
 
 Differential Diagnosis. In cases where primary 
 insanity resembles melancholia or mania an exact ana- 
 lysis of the delusions will exclude these psychoses. In 
 hallucinatory insanity the mood of the patient changes 
 very often, while in paranoia the patient's emotional at- 
 titude is comparatively lasting. Besides, the hallucinat- 
 ing patient is not possessed of well-defined ideas of fur- 
 therance and grievance. The differentiation from sec- 
 ondary insanity will be pointed out later. 
 
SPECIAL PATHOLOGY i8i 
 
 Course. Primary insanity is sometimes interrupted 
 by a transitory standstill during which the patient appears 
 entirely normal. After a lapse of some time the mental 
 disease sets in again. Caution is, therefore, required in 
 giving the prognosis after all morbid symptoms of para- 
 noia have disappeared. Complete recovery must not be 
 assumed before a sufficient time has passed without signs 
 of mental disorder. Paranoia as such never leads to 
 death. The mental disease may last 10-20 years, and yet 
 the patient may remain in a fairly good physical con- 
 dition. 
 
 Therapy. The treatment of paranoia is purely 
 symptomatic. Artificial feeding becomes necessary in 
 some cases (p. 143). The primarily insane patients are 
 dangerous to themselves and to others and must, there- 
 fore, be carefully watched, especially in view of the fact 
 that they are often very circumspect. They are capable 
 of simulating recovery before their physician and their 
 relatives to gain a free hand for the execution of their 
 pernicious plans. 
 
 Chapter LXXVI. 
 SECONDARY INSANITY. 
 
 Secondary insanity develops from primary insanity 
 or forms its continuation. It is, therefore, important to 
 draw the dividing line between the two, to determine 
 when a paranoiac is to be considered as secondarily 
 insane. 
 
 Symptom-complex. The affective sphere shows no 
 disturbance. The patient's mood is normal and tranquil 
 as long as his fixed ideas are not evoked. The ideational 
 sphere is characterized by fixed delusions (Ch. 30, p. 59) 
 
i82 PSYCHE 
 
 which constitute the pathognomonic symptom of the 
 mental disease. The voHtional activity is not disturbed, 
 but the fixed delusions sometimes cause an increase of 
 energy (p. 85). In the vegetative sphere there is noth- 
 ing abnormal. Sleep is not impaired. Appetite, diges- 
 tion, and assimilation are good. 
 
 Clinical Picture. There is no morbid change in 
 the aflfective sphere. The patient reacts in a normal man- 
 ner to external influences. In his conversation he speaks 
 calmly and reasonably, so that nothing unusual can be 
 noticed in him. But when his fixed delusions are touched 
 upon, he becomes lively and agitated, and if they are 
 slighted or contradicted, violent emotions may be called 
 forth. A few words may suffice to upset the patient's 
 mental balance. 
 
 The chief criterion for the diagnosis of secondary 
 insanity are the fixed delusions. Delusions are desig- 
 nated as fixed when they are no more supported and 
 nourished by morbid changes of the affective state or by 
 hallucinations, but persist, although these causative fac- 
 tors of delusions have ceased long ago (Ch. 30, p. 59). 
 With the establishment of fixed delusions permanent 
 feeble-mindedness has been proved. Aside from his 
 fixed delusions the patient's judgment is quite normal, 
 and he may even be very intelligent, but in the province 
 of these unchangeable wrong notions he is entirely devoid 
 of the slightest reasoning power. They occupy, as it 
 were, an isolated position in his mentality and exert no 
 influence on his character and conduct. He performs 
 acts which are strikingly incompatible with and contra- 
 dictory to his insane ideas. While a primarily insane pa- 
 tient possessed by the delusion of being heir to the throne 
 refrains from any vulgar work considering it below his 
 
SPECIAL PATHOLOGY 183 
 
 Royal dignity, the secondarily insane patient harboring 
 the same idea is not ashamed of, and does not abstain 
 from, the most humble labor. He does not feel the con- 
 tradiction between his low occupation and his high no- 
 tion of being a king. This inconsistency indicates that 
 mental enfeeblement has resulted from the preceding pri- 
 mary insanity. Only when the patient is provoked, when 
 he is reproached for doing w^ork unbecoming a king, he 
 abandons it and conducts himself in conformity with his 
 delusion. But his dignified bearing does not last any 
 longer than the emotion produced by the provocation. 
 When after a comparatively short time the emotion has 
 subsided, he resumes the work unworthy of His Royal 
 Highness. 
 
 The volitional activity is entirely normal in all mat- 
 ters not relating to the contents of the insane ideas. But 
 when the patient has been exasperated through allusion 
 to his delusions, he displays great energy and is even apt 
 to perform dangerous acts. 
 
 Differential Diagnosis. A secondarily insane 
 patient, while not in a stage of exacerbation (see Prog- 
 nosis), can easily be distinguished from a paranoiac in 
 the first attack. It happens, however, that primary in- 
 sanity makes a standstill and then recurs (p. 181). The 
 following paranoiic attack differs very little from sec- 
 ondary insanity if the first attack has resulted in some 
 mental enfeeblement with fixed delusions.* The main 
 differentiating feature is that in recurrent paranoia new 
 delusions arise, which is not the case in secondary insanity 
 unless it becomes aggravated by an exacerbation. Sec- 
 ondary insanity in a stage of exacerbation is equivalent 
 to recurrent paranoia associated with mental enfeeble- 
 ment which has been brought about by a previous attack. 
 
i84 PSYCHE 
 
 Course and Prognosis. There is no recovery from 
 secondary insanity. Sometimes the mental disease makes 
 even further progress through the arising of exacerba- 
 tions with new delusions. After the cessation of such an 
 acute attack the recent delusions remain permanent, be- 
 come fixed. In this way several groups of fixed delu- 
 sions, belonging to different attacks and mutually inde- 
 pendent, are established. Now one system of delusions 
 occupies the patient's mind, now another. A patient who 
 has gone through many exacerbations, retaining new de- 
 lusions after every attack, may be entirely confused and 
 unintelligible to the observer. 
 
 Therapy. The possibility of the disease making 
 further progress is important in the treatment of sec- 
 ondary insanity. As a rule, the patients are harmless 
 and fit for work. They may, therefore, be employed in 
 the asylum in a useful manner. When an exacerbation 
 arises, they become again distrustful and discontent and 
 are to be treated like primarily insane patients. 
 
 Secondarily insane patients may be left in private 
 care. The mental faculties that have remained intact 
 are to be fostered with special attention and stimulated 
 judiciously by appropriate occupation. It is not neces- 
 sary to exclude the patients from society. Their rela- 
 tives must be instructed to avoid discussing in conversa- 
 tion anything that could be construed as bearing upon 
 the contents of the fixed delusions. 
 
 When provoked secondarily insane patients may 
 commit criminal acts and thus come into conflict witli 
 the Penal Code. They are, then, to be deemed irre- 
 sponsible in the same way as at the time when their delu- 
 sions were still supported by hallucinations. 
 
SPECIAL PATHOLOGY 185 
 
 Chapter LXXVIL 
 DELIRIUM. 
 
 Symptom-complex. Great excitability of the cen- 
 tral nervous system forms the basis of many symptoms 
 of delirium. The affective state is marked by consider- 
 able fluctuations, sadness, cheerfulness, anger, fright, 
 etc., alternating frequently. The ideational sphere is 
 characterized by hallucinations in several senses, by in- 
 coherence and flight of ideas. Consciousness is dis- 
 turbed to a greater or lesser degree. The frequency of 
 the volitional manifestations and the energy are in- 
 creased. In the somatic sphere high fever is often pres- 
 ent. The patient impresses the observer as being danger- 
 ously ill. He takes very little nourishment, and the 
 assimilation is greatly reduced. The strength of the pa- 
 tient decreases perceptibly. Sleep is disturbed or lack- 
 ing altogether, but also soporous conditions are met 
 with. 
 
 Clinical Picture. The patient is greatly agitated. 
 Even when lying in bed, too weak to keep himself erect, 
 he is not quiet for a moment, but is continually tossing 
 about. His consciousness is benumbed. In his frequent 
 soliloquies he reveals bewilderment. When spoken to, he 
 answers but irrationally or not at all. He is not clear 
 about time and place, does not recognize his surroundings 
 — disorientation — and presents the symptom of con- 
 founding persons, believing to see old acquaintances in 
 people he has never known. The patient's confusion is 
 still more enhanced by manifold hallucinations which 
 produce strong emotions. Now he laughs, now he cries 
 or ejaculates exclamations of terror. 
 
 The movements of the patient are rapid, forceful. 
 
i86 PSYCHE 
 
 uncertain, so that he often hurts himself. A peculiar 
 symptom is falling down which appears to be intentional. 
 It happens that the patient stands quietly for some time. 
 Suddenly he drops to the ground, the body rigid, on his 
 face or on the back, receiving considerable injuries. 
 
 The energy is sometimes very much increased. A 
 delirious patient so feeble that he has to be kept in bed, 
 may unexpectedly leave it and rush towards the door 
 intent upon escaping. By a sudden jump through the 
 window he may end his life. The patient's death in such 
 a case is not due to suicidal intention, but to confusion 
 or to the compelling force of terrifying hallucinations. 
 A delirious patient is also dangerous to others. He may 
 assault any one coming near him in a reckless manner, 
 making use of any murderous instrument. 
 
 A patient in delirium usually rejects nourishment. 
 He would even eject food introduced into his mouth. At 
 times he hastily swallows down something. The refusal 
 of food is aggravated by fever which is very common in 
 delirium. The appearance of the patient is that of one 
 seriously ill. His face is somewhat flushed, his eyes are 
 without lustre. Now and then he perspires abundantly. 
 The lack of sleep and of nourishment, the fever, and the 
 restlessness contribute to reduce the patient's strength 
 perceptibly and rapidly. 
 
 The deliria are usually of toxic origin. They are 
 caused by chronic poisoning, as through alcohol, mor- 
 phine, cocaine, etc., or by the toxines of the acute infec- 
 tious diseases. In some cases of delirium no direct toxic 
 factor is demonstrable. Epileptic patients even without 
 indulging in intoxicants are subject to deliria representing 
 psychical equivalents (p. 243-244) of the epileptic at- 
 
SPECIAL PATHOLOGY 187 
 
 tacks. A peculiar delirium of unknown origin is the de- 
 lirium acutum which will be treated later (p. 263). 
 
 Differential Diagnosis. Delirium sometimes re- 
 sembles maniacal excitement. But a maniac's cheerful 
 mood is rather lasting, while an eventual cheerfulness in 
 delirium disappears quickly. The consciousness is hazy 
 in delirium, but clear in mania. A patient in maniacal 
 excitement has a rather florid countenance and a healthy 
 appearance, a delirious patient looks seriously ill, hectic. 
 Refusal of food does not occur in mania, but is frequent 
 in delirium. It happens, indeed, that a maniac does not 
 take food. But this is due to intense excitement which 
 renders the patient unable to carry out the movements 
 necessary for taking food. When in such a case the food 
 is put into his mouth or he is otherwise helped, he swal- 
 lows it even with eagerness. A delirious patient rejects 
 the food even when it is handed to him. He spits it out 
 when it is put into his mouth. 
 
 It is sometimes very difficult to differentiate delirium 
 from hallucinatory insanity. Consciousness in the lat- 
 ter psychosis, even when the hallucinations are ever so 
 vivid and varied, is never impaired to such an extent as in 
 delirium. The strength of the hallucinating patient does 
 not sink as rapidly as that of a patient in delirium. Fever 
 is often present in delirium, but is absent in hallucinatory 
 insanity. The anamnesis may^also help to clear up the 
 diagnosis. In a patient who is suffering from an acute 
 infectious disease, or in an epileptic, delirium is to be 
 assumed rather than hallucinatory insanity. 
 
 Course and Prognosis. The duration of delirium 
 is short. It varies between a few hours and 4-6 weeks. 
 Usually delirium terminates in recovery, but many a pa- 
 tient succumbs directly to the deleterious effects of the 
 
1 88 PSYCHE 
 
 mental disorder notwithstanding the best care and cir- 
 cumspection in the treatment. The physician must there- 
 fore be cautious in the prognosis of deHrium. 
 
 Therapy. Dehrious patients require careful watch- 
 ing. They must be guarded against self -in jury. Spe- 
 cial attention is to be paid to the nutrition of the patients. 
 When their strength sinks rapidly, artificial feeding must 
 be instituted without delay by introducing food per rec- 
 tum or through the stomach tube. Only nutrient liquids, 
 easy of absorption, are to be used for this purpose. It is 
 necessary to avoid giving too much food. 
 
 For the sake of saving the patient's strength and of 
 preventing exhaustion, medicaments are necessary to quiet 
 him. Before administering hypnotic drugs heart and 
 lungs must be carefully examined. Otherwise it may 
 happen that after taking 2 grams of chloral hydrate, for 
 instance, the patient falls into a sleep from which he does 
 not awake. An appropriate way of giving medicines is 
 hypodermic injection which is less difficult than medica- 
 tion per OS. Strict disinfection of skin and hypodermic 
 syringe is necessary, as an eventual phlegmon may easily 
 lead to gangrene because of the weakened condition of 
 the patient. A sedative effect on very restless patients is 
 derived from wet packings and protracted warm baths. 
 But these procedures can be employed only with great 
 difficulty on account of the resistance of the patients. 
 
SPECIAL PATHOLOGY 189 
 
 Chapter LXXVIIL 
 
 SECONDARY FEEBLE=MINDEDNESS, SECONDARY 
 DEMENTIA. 
 
 Secondary dementia is the result of a psychosis. It 
 shows many gradations of which the hghter ones may 
 be designated as secondary feeble-mindedness. 
 
 In some instances a diminution of mental capacity 
 is perceptible only to the intimate acquaintances of the 
 patient, while other people would hardly recognize in 
 him any mental weakness. In other instances every 
 mental faculty of the patient has been annihilated. Be- 
 tween these two extremes there are many more or less 
 grave forms of secondary dementia. 
 
 Agitated and apathetic dementia have been distin- 
 guished. Some patients are lively and manifest a cer- 
 tain restlessness, others are very quiet and mute. Which 
 of these two forms will be present, depends upon the 
 original psychosis. In secondary dementia resulting from 
 mania the patient would, from time to time, fall into a 
 state of excitement, of much lower intensity though than 
 that of the primary mania. If the dementia is the out- 
 come of a psychosis in which excitative states are rare, 
 it shows the apathetic character. 
 
 Symptom-complex. There is an impairment of 
 the affective sphere ranging from a diminution of the 
 affective tones to complete obliteration of all feeling 
 (Ch. 17, p. 36). Similar conditions prevail in the idea- 
 tional province. The production of ideas is only les- 
 sened in some instances, in others hardly any idea arises 
 in the patient's consciousness, so that the whole treasure 
 of experiences stored up in his brain seems to have been 
 wiped out by the preceding psychosis. Memory and 
 
190 PSYCHE 
 
 power of understanding are more or less reduced, in 
 aggravated cases both functions have been abolished. As 
 to the activity of the will there is in agitated dementia an 
 increase of the frequency of volitional manifestations, 
 and a decided diminution of the energy of persistence 
 (pp. 84, 86). In apathetic dementia both are decreased. 
 The vegetative functions proceed, as a rule, normally. 
 The physical condition of the patient is, therefore, 
 usually satisfactory. Yet they readily acquire other dis- 
 eases, as tuberculosis. 
 
 Clinical Picture. The patient is constantly in a 
 mood of indifference and indolence. He takes no inter- 
 est in his surroundings and is very little concerned about 
 his own affairs and the welfare of his nearest relatives. 
 In his speech and conduct he betrays poverty of ideas. 
 The deficiency of his memory shows itself in his inability 
 to remember especially events antedating his acute mental 
 malady. He has not progressed with time. When ques- 
 tioned in which year he is living, he would frequently 
 name another than the current year, generally the one in 
 which he first became mentally ill. If a demented patient 
 is frequently overheard to mention, in his soliloquies, a 
 certain year, the assumption is justified that his mental 
 derangement has commenced in that year. 
 
 In agitated dementia the patient manifests some 
 excitement. He walks up and down the room, tugs at 
 his clothes, pulls and twists his hair, and handles any- 
 thing he can get a hold of. All his manipulations are to 
 no purpose. He utters often incomprehensible words 
 and broken sentences. Mechanically he repeats one and 
 the same phrase for hours (verbigeration). In apathetic 
 dementia the patient is quiet, speaks very little, and per- 
 forms but few volitional acts. 
 
SPECIAL PATHOLOGY 191 
 
 The capacity of understanding is markedly dimin- 
 ished. The patient does not comprehend the simplest 
 questions and gives very superficial answers. He has no 
 clear conception of time and place. He leads more or 
 less a mechanical life, according to the regulations prev- 
 alent at the asylum. Left to his own guidance, he would 
 be unable to observe any order of affairs. He would eat 
 and drink to excess and at improper times, he would 
 swallow harmful food, gulp down fluids which are too 
 hot, etc. He would neglect the cleanliness of his body, 
 he would remain in bed for days, not leaving it even to 
 relieve nature, and then again he would not go to bed for 
 several days. He would expose himself to cold, insuffi- 
 ciently clad, and would sit in the direct sunlight for hours. 
 He is dependent for his welfare upon others, being help- 
 less when left alone. 
 
 The vegetative functions, as appetite, digestion and 
 assimilation of food, and sleep, are normal in agitated 
 dementia. In apathetic dementia disturbances of the 
 vegetative processes occur, but they are brought about 
 only by the apathy. Owing to continued lack of muscular 
 movements the circulation is sluggish. The lower ex- 
 tremities become swollen, the face looks bloated. The 
 lack of physical exercises causes heart weakness. These 
 evils can be obviated by proper care, a proof that they 
 are due to the apathy, not to the dementia as such. 
 
 Sometimes the question is to be decided how long 
 a patient has been demented, whether his dementia has 
 existed since earliest youth, or has commenced at a later 
 age. To arrive at a decision fragments or remnants of 
 a former education are to be sought after. Sometimes 
 the patient surprises his observer by uttering Latin or 
 Greek words or some scientific technical terms. After 
 
192 PSYCHE 
 
 the detection of such fragments of former schoohng and 
 learning there is no doubt that the patient was in full 
 possession of his mental faculties at least until the age 
 when higher educational accomplishments are attained. 
 
 Differential Diagnosis. It is possible to con- 
 found secondary with primary dementia. But the an- 
 amnesis reveals that the former has been preceded by a 
 psychosis, the latter by some other acute disease. In the 
 absence of an anamnesis, the differentiation can be made 
 only by a somewhat extended observation of the case. 
 In primary dementia the patient improves quite rapidly, 
 while in secondary dementia even after months no change 
 in the patient's condition is noticeable. 
 
 Course and Prognosis. Secondary dementia is 
 incurable. The mental condition of the patients does not 
 improve. On the contrary, observation of the patients, 
 extending over many years, shows that from time to 
 time something of the remains of mental faculty crumbles 
 off, the dementia thus gradually progressing. Unlike 
 other psychoses, for instance delirium, dementia as such 
 never leads to death. If no intercurrent disease super- 
 venes, demented patients may attain old age. 
 
 Chapter LXXIX. 
 
 PRIMARY MENTAL WEAKNESS, PRIMARY 
 CURABLE DEMENTIA. 
 
 After grave infectious diseases or abundant loss of 
 blood the patients may remain in a state of great mental 
 weakness. Although the fever has ceased, and appetite, 
 digestion, assimilation, and sleep are normal again, their 
 vigor of mind is but slowly restored. The psychical func- 
 
SPECIAL PATHOLOGY 193 
 
 tions continue to be sluggish and defective, and thus the 
 patients create the impression of being demented. They 
 are indifferent to everything and everybody around them 
 and poor in ideas. The memory is debihtated, the fre- 
 quency of vohtional manifestations is diminished, the 
 energy is lowered. The vegetative functions, however, 
 proceed fairly well. 
 
 This symptom complex, coinciding with that of sec- 
 ondary dementia, is founded solely upon a state of gen- 
 eral exhaustion in which the mental faculties have been 
 more unfavorably affected than the vegetative functions, 
 so that the recuperation of the vigor of mind has been 
 rendered more difficult and requires more time than the 
 restoration of the general health. 
 
 Course and Prognosis. Primary feeble-minded- 
 ness ordinarily ends in restitutio ad integrum and is of 
 comparatively short duration. It is possible, however, 
 that recovery does not ensue and the dementia remains 
 permanent. But such a termination is to be assumed 
 only after the mental weakness has persisted unchanged 
 for a very long time, for many months following the 
 acute disease by which it has been produced. 
 
 Differential Diagnosis. The anamnesis is of 
 chief importance in the recognition of primary mental 
 weakness. It shows that a severe acute disease has re- 
 cently preceded. But also through mere observation of 
 the case primary and secondary dementia can be distin- 
 guished from one another. In primary dementia some 
 improvement is already noticeable after a short time, one 
 or two weeks. The patient shows more interest for his 
 surroundings, produces more ideas, displays pleasure at 
 the visit of a friend, etc., while in the beginning he was 
 indifferent to everything. In secondary dementia, how- 
 
194 PSYCHE 
 
 ever, even after a year no change in the patient's mental 
 condition is perceptible. 
 
 Therapy. Owing to the favorable progress of the 
 vegetative functions the treatment does not offer much 
 difficulty. The patient should not receive too much al- 
 cohol as a stimulant. In intellectual respect care must be 
 taken that the patient is not overtaxed in the least. When 
 he begins to manifest some interest in his surroundings, 
 to show that he is not indifferent to the call of a friend, 
 etc., relatives and attendants should not think that they 
 ought to animate and exhilerate him as much as possible, 
 to allow him to receive as many friends as he would wish, 
 to let him hear all kinds of news, etc. On the contrary, 
 it is necessary to be reserved. The patient's mental pow- 
 ers must be spared and not tasked much. 
 
SECTION 11. 
 
 MENTAL DISEASES DATING FROM EAR- 
 LIEST CHILDHOOD, IDIOCY, CRETINISM 
 
 Chapter LXXX. 
 
 DEFINITION, CLASSIFICATION, AND PHYSICAL 
 STIGMATA OF IDIOCY. 
 
 Individuals who have been affected with cerebral 
 diseases either in foetal Hfe or as very young children 
 and in consequence thereof are afflicted with mental de- 
 fects traceable to early childhood are designated as idiots. 
 
 A young child may acquire an acute psychosis in the 
 same way as an adult. When the sanity of the child is 
 not fully restored, but permanent feeble-mindedness, 
 more or less pronounced, results from the psychosis, the 
 child becomes an idiot. In idiocy, therefore, we are deal- 
 ing with deficiencies of the mind, not with acute psycho- 
 pathological processes. The mental defects remaining 
 after acute psychoses of adults constitute the clinical pic- 
 ture of secondary dementia (Ch. 78, p. 189), acute psy- 
 choses of young children, however, produce idiocy unless 
 complete recovery takes place. 
 
 Idiocy presents itself in many gradations which have 
 been divided into two principal classes, namely superior 
 idiocy and inferior idiocy, the faculty of speech furnish- 
 ing the dividing line. Idiots who do not speak at all or 
 very little have been called inferior idiots, those who 
 master the language perfectly or almost so have been 
 
196 PSYCHE 
 
 designated as superior idiots or imbeciles. Among the 
 latter are also counted individuals who manifest a single 
 mental defect and are otherwise normal, for instance, 
 patients affected with moral insanity, querulous in- 
 sanity, originary insanity, sexual perversity. Etiologi- 
 cally cretinism has been separated from idiocy. Cretin- 
 ism comprises a sum of physical and mental defects at- 
 tributable to a definite territorial cause, i. e., to conditions 
 of the soil prevailing in a certain region (p. 214). Every 
 cretin is an idiot, but not every idiot is a cretin. 
 
 In somatic respect some idiots exhibit physical signs 
 from which their idiocy may be inferred. Especially the 
 configuration of the skull is apt to betray idiocy. Macro- 
 cephalia, microcephalia, and obliquity of the skull are 
 met with in idiots. These anomalies are sometimes due 
 to premature synostoses of cranial sutures. Macroce- 
 phalia is brought about by hydrocephalus in early child- 
 hood or by meningitis with abundant secretion of cere- 
 brospinal fluid. The brain is smaller than normally in 
 microcephalia. If it appears larger, this is due to a wid- 
 ening of the cerebral ventricles through hydrocephalus 
 inter nus. 
 
 The features of the face, quite normal in childhood, 
 become sometimes irregular at the age of puberty. A 
 disproportion arises between the facial and cerebral parts 
 of the skull, producing an unsightly appearance, which 
 may be still more enhanced by the presence of a large 
 goitre. 
 
 Impairment of the general growth of the body oc- 
 curs in idiocy ; some idiots remain dwarfs. 
 
 Other somatic defects met with in idiots consist in 
 motor disturbances. Some idiots are affected with par- 
 eses or even with complete hemiplegia. With the latter 
 
SPECIAL PATHOLOGY 197 
 
 motor disturbance there is usually associated an asym- 
 metry of the skull, the heterolateral cranial half being 
 smaller than the homolateral. An eventual autopsy shows 
 that one cerebral hemisphere is reduced in size, while the 
 cerebellar hemisphere of the same side is either smaller 
 or larger than normally. 
 
 Some idiots are affected with epilepsy. A vicious 
 circle is thus established. For epilepsy itself reduces 
 gradually the mental faculties. Epileptic idiots show, 
 therefore, a progress of their psychical defects. This 
 can be recognized when there is opportunity to observe 
 such patients in their early youth and at a later age. 
 
 In some cases of idiocy the autopsy reveals pro- 
 nounced loss of cerebral substance, porencephalia. 
 
 Chapter LXXXI. 
 INFERIOR IDIOTS. 
 
 The inferior idiots are characterized by great im- 
 pairment of speech. All their psychical faculties are 
 more or less defective. In the affective sphere they re- 
 semble small children. They are very irritable, weep at 
 the slightest cause, and fall readily into despondency. 
 They are devoid of the finer gradations of feeling so 
 numerous in well-developed individuals. They lack the 
 wealth of emotions of normal persons, being capable 
 only of the extreme emotional manifestations, such as 
 unbounded exultation, pain, wrath, despair, etc. Of 
 ethical notions, of conceptions of filial love, decency, 
 honor, duty, there is no vestige in them. They are want- 
 ing even in such expressions of the affective sphere as 
 
198 PSYCHE 
 
 are met with in some animals, for instance gratitude, 
 attachment, faithfulness. 
 
 The power of understanding is considerably les- 
 sened. The intelligence of the inferior idiots is so low 
 that they are unable to repeat words when urged to do so. 
 They hear sounds, for it is possible to demonstrate that 
 they are not deaf, yet they do not retain in mind the 
 auditory images necessary for speech. Some inferior 
 idiots learn to know the names of things. Requested to 
 bring a certain object they would fetch it, but they can- 
 not repeat the name of the object when it is pronounced 
 before them, and this not because they are affected with 
 paralysis of the motor organs of speech, but because they 
 lack the energy and understanding needed for an attempt 
 to repeat words. 
 
 The inferior idiots speak, after the manner of small 
 children, in infinitives. 
 
 A remarkable symptom of inferior idiocy is the want 
 or defectiveness of self-consciousness. A child learns 
 quite early to distinguish its own person from the ex- 
 ternal world, i. e., it acquires self -consciousness (p. 28). 
 It arrives at knowing the little word "L" Small children 
 when asked who has done this or that would reply with 
 their name instead of saying "1." As they advance in 
 intelligence, they begin to answer with *T," showing 
 hereby that they have reached a fair degree of self -con- 
 sciousness. Many inferior idiots remain on the first 
 stage, speaking of themselves in the third person. 
 
 The low intelligence of inferior idiots becomes very 
 obvious by their failure to recognize and shun evils which 
 they have experienced a short while ago. The inferior 
 idiot will touch the red hot coal which has just given him 
 a painful burn. 
 
SPECIAL PATHOLOGY 199 
 
 The memory of inferior idiots is, as a rule, as 
 poor as their intelHgence. But in some instances it is re- 
 markably good, in striking contrast with the other mental 
 faculties. 
 
 In the volitional sphere the inferior idiots display 
 an impulsive character. They are unable to control them- 
 selves. A trifle may throw them into great agitation. 
 Sometimes they would run about wildly in the room or 
 they would sit and constantly make rocking movements. 
 They are wavering, fickle, incapable of acting with de- 
 sign and deliberation. When they accomplish some mis- 
 chief, they do it without preconceived intention. Some- 
 times, however, they exhibit great perseverance in the 
 execution of certain acts (p. 85). Some idiots have a 
 predilection for fire and may hereby cause arson. There 
 is nothing specific in this symptom. Children, too, are 
 fond of fire; they like to light matches. Characteristic 
 pyromania is, therefore, not to be ascribed to inferior 
 idiots. The entire volitional sphere of inferior idiots is 
 characterized by unbridled passions. 
 
 It is chiefly the inferior idiots who exhibit the phy- 
 sical stigmata and other somatic disturbances, such as 
 asymmetry of the skull, pareses, epilepsy, etc., which 
 have been mentioned in the preceding chapter. 
 
 Chapter LXXXII. 
 SUPERIOR IDIOTS, IMBECILES. 
 
 The superior idiots or imbeciles differ from the in- 
 ferior idiots by the faculty of speech. As a rule they 
 possess an adequate knowledge of language. 
 
 In the affective sphere the extreme emotional mani- 
 
200 PSYCHE 
 
 festations prevail. The imbeciles are very excitable, 
 readily susceptible of grief and anger. Such emotions 
 reach extraordinary intensity. A trifle makes the im- 
 beciles chafe with fury. The emotions last unusually 
 long. The imbeciles persist in an emotion of fierce wrath 
 or deep sadness for hours and days. In such a frame of 
 mind they are apt to commit dangerous acts. A good 
 many cases of suicide are to be ascribed to imbecility. 
 
 There are no marked defects in the ideational sphere. 
 On the contrary, some imbeciles are endowed with an 
 excellent memory and are thus enabled to acquire a great 
 wealth of experiences which they have readily at their 
 disposal (pp. 62-63). But the intelligence of the im- 
 beciles is defective and their memory is one-sided. It 
 works mechanically without selection, retaining the en- 
 tirely insignificant things just as well as the most im- 
 portant ones. The former would not impress themselves 
 on a memory which is aided by a good understanding 
 and, therefore, capable of separating the things to be kept 
 from those to be cast aside as of no value. 
 
 Owing to their marvelous memory, many superior 
 idiots are not recognized as such in school, but, on the 
 contrary, are considered to be very gifted pupils. This 
 mistake occurs especially when they are somewhat good- 
 natured, not obstinate, and their irascibility is slight. A 
 closer examination, however, reveals that the talented 
 imbeciles lack the proper understanding of what they 
 have studied, that they have learned everything in a me- 
 chanical way, by heart, and reproduce, like a dictionary, 
 other people's opinions and judgments which are always 
 at their disposal because of their unfailing memory 
 
 (p. 63). 
 
 Ordinarily, however, the education lays bare the 
 
SPECIAL PATHOLOGY 201 
 
 mental defectiveness of the imbeciles. Imbecile children 
 cannot adapt themselves to order and rule, cannot bear 
 censure, much less punishment. When they are chastised, 
 they become morose and stubborn, do not know^ at all 
 what is going on, and are throw^n into emotions of blind 
 rage rendering them entirely irresponsible. It is, there- 
 fore, not conducive of good, and may even be detri- 
 mental, to punish imbecile children. When they are 
 locked up for ill behavior, they are apt to jump out of the 
 window with fatal consequence. 
 
 Imbeciles are incapable of imbibing certain concep- 
 tions. Although they have heard of duty, honor, friend- 
 ship, filial love, etc., and know the terms well; they are 
 not fully alive to them. Normal persons having acquired 
 these ethical conceptions through education and associa- 
 tion experience a certain feeling, are put into a certain 
 mood, whenever their mind is turned upon such ethical 
 subjects. This feeling influences all their actions. Im- 
 beciles, however, lack the normal affective tones accom- 
 panying ethical ideas and are, therefore, unable to con- 
 form their conduct accordingly. No sense of duty is 
 inculcated upon their mind notwithstanding the best edu- 
 cation they may have received. They cannot abide in a 
 situation for any length of time, but crave for one change 
 of occupation after the other. This fickleness and un- 
 steadiness in desires and aims appear as an early symp- 
 tom. Imbecile children are very prone to run away at 
 random. They escape from their parents or simply do 
 not return home from school. When they grow older 
 and assume situations, they do not keep them very long. 
 Suddenly they decamp without any valid reason. At the 
 slightest disagreeable occurrence they abandon their work 
 and leave without any regard for the future. Sometimes 
 
202 PSYCHE 
 
 they would abide by one occupation for a longer while, 
 perhaps for a year or so, but then they would change it 
 too. By this want of perseverance imbecility may be 
 recognized even in such cases where it is of a slight 
 degree. 
 
 Individuals of mental inferiority have a high opinion 
 of themselves, think that their knowledge is great, and 
 are self-complacent, while normal persons, even if they 
 have studied very much, feel with a sort of dissatisfac- 
 tion and are conscious that they know little in compari- 
 son to what they still have to learn. 
 
 The mental inferiority of imbeciles is easily recog- 
 nized when they are placed in a situation requiring strict 
 submission to prescribed rules, as the military service. 
 In the beginning they may conduct themselves fairly 
 well, but after some time they usually become unman- 
 ageable. They cannot observe the requisite discipline and 
 contract punishment after punishment. This, however, 
 fails to make them reform their ways so that they re- 
 main incorrigible. 
 
 When however imbeciles are living in simple circum- 
 stances, their psychical defectiveness may pass unno- 
 ticed. Should such individuals become subject to legal 
 consideration, it would be very difficult for the medico- 
 legal expert to prove to the judge that he is dealing with 
 imbeciles. Since the imbeciles know the ethical concep- 
 tions only by name, they frequently come into conflict 
 with the Penal Code through vicious acts committed in 
 emotional fits, through offenses against morality, through 
 arson executed for revenge, etc. 
 
 In somatic respect the imbeciles usually show no 
 deviation from the normal. In some cases microcephalia 
 is met with or an excessive thyroid gland with cystic 
 
SPECIAL PATHOLOGY 203 
 
 degeneration. The whole physiognomy then presents a 
 certain pecuHarity from which mental inferiority may be 
 inferred. The autopsy of imbeciles sometimes reveals a 
 diminution of the weight of the brain or a division of one 
 of the frontal convolutions, the number of which is thus 
 increased to four. Defects of the corpus callosum are 
 found in some cases. 
 
 The family physician having convinced himself of 
 the imbecility of a child should call the attention of the 
 parents to its mental weakness and advise them to regu- 
 late its education accordingly. An imbecile child must 
 not be overtasked. Chastisement for disobedience or ill 
 behavior must never be resorted to. For severity ren- 
 ders the imbecile still more inflexible, and nothing can 
 be accomplished by it. Great difficulty is encountered 
 when there are normal children in the family. Removal 
 from home of the imbecile child is then called for by all 
 means. To put imbecile children into an asylum for 
 idiots is not advisable. For in such an institution they 
 are liable to come in contact with inferior idiots which 
 may be harmful to them. Special institutions, therefore, 
 ought to be established for the education of imbeciles. 
 
 Imbecile children who are reared in their own homes 
 grow up to be the worst elements of society. The family 
 physician ought to write down his observations of an 
 imbecile child in the form of documentary records. They 
 may become very useful in the future when the adult 
 imbecile is summoned to court to answer for mis- 
 deeds. 
 
204 PSYCHE 
 
 Chapter LXXXIII. 
 MORAL IDIOCY, MORAL INSANITY. 
 
 Of all the idiots those affected with moral insanity 
 have sustained the least impairment of mental capacity. 
 They show defects only in moral respect, but otherwise 
 they are entirely sane. Formerly, and frequently now- 
 adays, the moral idiots were treated as criminals. In- 
 deed, it is very difficult to draw the dividing line between 
 those suffering from moral insanity and those imbued 
 with moral depravity. Yet the differentiation is very 
 important. For the moral idiots are unfortunate patients 
 who could not justly be called to full account for their 
 misdeeds, while the morally depraved individuals are re- 
 sponsible. 
 
 The symptoms of moral idiocy relate exclusively to 
 the affective sphere. The patients are not influenced 
 by ethical conceptions in the same way as are normal 
 persons. The actions of the latter do not depend solely 
 upon understanding and reason. Any experience, any 
 idea arising in consciousness, any recollection of former 
 events and situations, produces in normal persons certain 
 alterations of the affective state, certain feelings. Espe- 
 cially ethical ideas are accompanied by impressive feel- 
 ings. These latter more than anything else are the chief 
 cause of normal persons acting in conformity with ethical 
 principles. There are, however, individuals in whom 
 ethical ideas fail to call forth the feelings they normally 
 give rise to. Such individuals lack the foremost incentive 
 to live up to ethical requirements. Again other individ- 
 uals receive the normal affective tones from actual oc- 
 currences, but not from the recollection of such occur- 
 rences. Thus they grieve very much at a restriction of 
 
SPECIAL PATHOLOGY 205 
 
 their freedom and promise solemnly to desist henceforth 
 from any act that would deprive them of their liberty. 
 Notwithstanding this keen feeling aroused by actual im- 
 prisonment the recollection of a former imprisonment 
 leaves them entirely indifferent, being devoid of the 
 normal affective tone associated with such recollection. 
 These individuals experience no feeling when they see 
 an evil approaching. Not before they are in the midst 
 of the painful situation do they feel grieved at it. Such 
 patients may have had ever so many severe lessons, the 
 remembrance thereof will not keep them back from ac- 
 tions which they know very well will make them undergo 
 again the same distressing experiences. 
 
 Moral idiocy is characterized by ''zvant of educa- 
 bility." This pathognomonic feature can be demonstrated 
 in all cases where efforts have been made to give the 
 individuals in question a good education. "Want of 
 educability" is no meaningless term, no vague trait that 
 may be overlooked, but a distinct symptom presenting 
 itself forcibly to the attention of the observer. It can be 
 .shown that a boy, morally defective, has had the same 
 education as his sane brothers and sisters, has been cher- 
 ished with the same love, has been censured, not to say 
 punished, with the same tender caution, or even that in 
 his education more care has been employed than with 
 the other children of the family. Yet all attempts to 
 make him a useful member of society have remained 
 without avail, while his brothers and sisters have ac- 
 quired good manners and character. This is "want of 
 educability." A few concrete examples will illustrate the 
 matter more clearly. A prominent psychiatrist relates a 
 case in which a widow had taken great care to educate 
 her only son, who was very naughty and insubordinate. 
 
2o6 PSYCHE 
 
 But all her endeavors remained unsuccessful. Finally 
 she applied to the director of a well conducted educational 
 institution. He consoled the worried mother, assuring 
 her that he would get the better of her unbridled son. 
 For he had had worse cases in which he had made good 
 men out of refractory boys who had appeared to be incor- 
 rigible. He took the boy into his institution. But a few 
 months later he wrote to the unhappy mother that he had 
 been mistaken in her son. All educational means to im- 
 prove his character would be futile. He had no concep- 
 tion of filial affection, honor, duty, etc., and was indif- 
 ferent to exhortation and reproach and insensible to pun- 
 ishment. For the sake of the other pupils he would have 
 to be removed from the institution as soon as possible. 
 This is ''want of educability." In another instance a boy 
 of a good family had been expelled from several schools 
 and had subsequently remained unruly. Finally his rela- 
 tives succeeded to put him into the army and to have him 
 assigned to a regiment the colonel of which was a friend 
 of the family. He promised to educate the young man. 
 The military institution has excellent educational means 
 at its disposal and subdues many a young man apparently 
 uneducable. One day our young soldier did not appear 
 at a military review. The colonel sent the strict order 
 that he should present himself forthwith. This per- 
 emptory command put the soldier into a state of sullen 
 stubbornness, and he flatly refused to obey the order, 
 although he well knew the imminent punishment. The 
 incident was, however, purposely disregarded and he was 
 not disciplined. Later he stole money from a military 
 office and was punished by confinement in a fortress. He 
 finished his military service without showing any im- 
 provement of character. Thereupon an uncle of his ad- 
 
SPECIAL PATHOLOGY 207 
 
 vanced the statement that his nephew was so wicked be- 
 cause he had never enjoyed a proper education. A person 
 of his disposition, he contended, ought to be dealt with 
 very leniently. He took his ill-bred nephew into his 
 house, proposing to make a good man of him. But his 
 attempts at education remained entirely fruitless, and he 
 finally had to admit that his nephew was lacking the 
 slightest feeling of gratitude, tact, and honor and was 
 incorrigible. Subsequently the young man was com- 
 mitted to an insane asylum. The director of the institu- 
 tion declared him to be a moral idiot. In the asylum his 
 conduct was very satisfactory. He soon opened a cor- 
 respondence with another uncle of his, sending him the 
 nicest letters. The uncle began to remonstrate with the 
 authorities of the insane asylum on the detention of his 
 nephew, contending that there is no such mental disorder 
 as moral insanity. He was finally coaxed by the gentle 
 and deferential writings of his nephew^ into removing him 
 from the insane asylum and taking him into his country 
 home. The young man conducted himself fairly well 
 until he once chanced to open a drawer containing money. 
 Instantly he grabbed the cash and escaped unnoticed. He 
 came to the city and squandered the money in company 
 with the servants of the insane asylum. All this proves 
 incontestably that the recollection of the many adversi- 
 ties and penalties had failed to arouse in the patient any 
 feeling whatsoever. This is "want of educability." 
 When this symptom, which extends over many years, can 
 be established, the diagnosis moral idiocy becomes un- 
 questionable. 
 
 If however no attempts at education have been made, 
 or, on the contrary, the individual in question has grown 
 up in pernicious environment and has been corrupted, it 
 
2o8 PSYCHE 
 
 may not be possible to differentiate moral idiocy from 
 moral depravity. A slight hint may perhaps be gained by 
 taking into consideration that even uneducated scamps 
 and criminals have some sense of companionship and 
 friendship, some feeling of honor, a certain willingness 
 to make sacrifices for others, while the moral idiots are 
 devoid even of such traits. 
 
 Want of the affective tones which accompany ethical 
 ideas is common to plain imbecility and moral idiocy. 
 But in the latter it forms a predominant feature. Be- 
 sides, in moral idiots intelligence and emotions are quite 
 normal, while in imbeciles the intelligence is deficient and 
 the emotions are of frequent occurrence and of extra- 
 ordinary intensity and duration. It is hardly possible, 
 but practically of no importance, to distinguish moral 
 idiocy from cases of imbecility in which emotions are 
 little prevalent and a good memory hides the deficient 
 intelligence.* 
 
 As to the management of moral idiocy it must be 
 borne in mind that punishment of the patients is not 
 conducive of good. 
 
 * In the case described by B. S. Talmey (Medical Record, 
 Nov. i6, 1907) the imbecile traits are so little pronounced that 
 the patient is to be considered a moral idiot rather than a "high- 
 grade imbecile" (superior idiot). This case is mentioned here 
 because of the remarkable somatic anomaly, or physical stigma 
 of cryptorchism. The patient had only one testicle. The other 
 could not be found even at an abdominal operation which he had 
 to undergo. 
 
SPECIAL PATHOLOGY 209 
 
 Chapter LXXXIV. 
 QUERULOUS INSANITY, MORBID LITIGIOUSNESS. 
 
 Querulous insanity is based on a defect in the feel- 
 ing of right and wrong. Some people are of a conten- 
 tious disposition. They seldom admit being in the wrong 
 even when they know that they are mistaken. But the 
 disputatiousness of a sane person has its limits. He is 
 sensible of his errors and confesses them to himelf 
 although he does not do so to others. The querulous 
 idiot, however, does not feel his errors. Even after they 
 have been clearly and incontestably demonstrated to him, 
 he thinks in his own heart and soul that he is right. 
 
 The querulous idiot, about to commence a legal ac- 
 tion, cannot conceive of the possibility that the court is 
 apt to decide in his disfavor. The consideration never 
 enters his mind that essential right cannot be upheld un- 
 less formal right is carefully observed. An honest person, 
 for instance, may suffer punishment by court through 
 malicious people who perjure themselves. The judge 
 has to inflict a penalty on the defendant in such a case. 
 A rational person would excuse the court, realizing that 
 the judge is not omniscient, that he has to act according 
 to certain formal principles. He would consider the 
 decree of penalty as correct in the common order of 
 things, as a misfortune for him in which he has to ac- 
 quiesce. The querulous idiot is unable to reason this 
 way. According to his feeling the administrator of jus- 
 tice has to exculpate him notwithstanding all evidence to 
 the contrary. When he is adjudged guilty, he considers 
 himself ignobly treated by the judge and is reluctant to 
 abide by his judgment. He cannot persuade himself that 
 
2IO PSYCHE 
 
 society must have an institution to decide controversies, 
 and that its decisions must be obeyed. 
 
 The outbreak of querulous insanity depends on an 
 accident, on an insignificant trifle. The patient, for in- 
 stance, walks over a place where thoroughfare is pro- 
 hibited. A small fine is imposed on him for the tresspass. 
 In this he does not acquiesce and makes all kinds of 
 efforts to prove that the prohibition was unjust. When 
 the court decides again in his disfavor, he declares that 
 the judge has been bribed. Now he is sentenced to a 
 penalty for defaming the judge. Again he does not 
 submit to the verdict and appeals. In this way after his 
 first collision with the courts he cannot extricate himself 
 from lawsuits. He goes from one court to the other 
 until the court of last resort, and finding nowhere satis- 
 faction, he threatens to obtain redress by force. 
 
 A forcible criterion for the morbidity of a case of 
 litigiousness lies in the patient's utter indifference to the 
 welfare of his family. He is willing to give up his whole 
 fortune, to endanger the subsistence of those dependent 
 upon him in order to get his pretended right. Another 
 criterion of morbidity is the extreme irritability which 
 the litigious imbecile displays whenever the conversation 
 turns upon his lawsuits. He cannot bear any contradic- 
 tion whatsoever, and the slightest difference of opinion 
 drives him out of his wits. Finally querulous insanity 
 may be inferred from a symptom which extends over 
 many years. In the course of time the intellectual pow- 
 ers of the querulous imbecile decrease, so that he passes 
 into a state of feeble-mindedness. This is an important 
 point for the distinction of a sane litigious person from 
 a querulous idiot. Besides, the former would abandon 
 
SPECIAL PATHOLOGY 211 
 
 his lawsuits when he sees that he puts all his fortune at 
 stake. 
 
 The querulous idiot finally lands in the insane 
 asylum. In the beginning he is not one of the most 
 agreeable patients. But after some time he ceases to 
 insist upon his pretended rights when he sees that other- 
 wise he would not be dismissed from the asylum. 
 
 Chapter LXXXV. 
 ORIGINARY INSANITY. 
 
 Originary insanity resembles primary insanity (Ch. 
 75, p. 176). Like the paranoiacs the originary idiots 
 also compose romances in which they themselves play the 
 principal part. But originary insanity is founded upon 
 congenital mental defects and appears already in child- 
 hood. 
 
 The originary idiots are unable to discriminate be- 
 tween what they are merely thinking of, i. e., their mem- 
 ory images, and that which their surroundings present 
 to their senses, i. e., their actual perceptions. To a slight 
 degree this quality is met with also in normal people. 
 Even a sane person does not always apprehend things 
 objectively, but frequently there is a subjective tinge in 
 his observations. Children dream in an awake state. 
 Without hallucinating they would point at objects, not 
 present, which they are merely thinking of. The normal 
 person, therefore, not only views the external world sub- 
 jectively, but even passes through a period in which he 
 mistakes his memory images for objective phenomena. 
 The originary idiots do not get out of this period at all. 
 
212 PSYCHE 
 
 They build castles in the air and believe in their existence. 
 In all sincerity they relate that they have participated in 
 great events which have never taken place. The position 
 they fancy to be in is in striking contrast v^^ith reality. 
 
 Patients affected v^^ith originary insanity may be 
 very intelligent in other respects. But they are unsuc- 
 cessful in life and shun society, and in their isolation they 
 would manifest other symptoms of morbid mentality. 
 There is a hereditary taint of insanity in their family, 
 and some patients are descended directly from insane 
 parents. 
 
 Chapter LXXXVI. 
 
 CONTRARY SEXUAL FEELING, SEXUAL PER- 
 YERSITY. 
 
 The most common manifestation of sexual per- 
 versity consists in -antipathy against the opposite, and 
 inclination to the same sex. Individuals showing this 
 anomaly are affected with a defect in the sexual sphere, 
 with contrary sexual feeling. But a difference is to be 
 made between those afflicted with sexual perversity as 
 a disease and those who indulge in all kinds of sexual 
 aberrations in consequence of surfeit in Venere and in 
 allegiance to the principle "variatio delectat." Patients 
 with contrary sexual feeling do not marry. When, un- 
 mindful of their abnormal condition, they do contract a 
 marriage, they are unable to fulfill their marital duties. 
 
 Contrary sexual feeling occurs also in women. 
 
 Pederasty is prohibited in many States. Patients 
 suffering from sexual perversity, therefore, frequently 
 come into conflict with the Penal Code. Non-freedom 
 
SPECIAL PATHOLOGY 213 
 
 of the will is usually not recognized as a defense for 
 pederastic aberrations, so that patients found guilty of 
 such misdeeds have to undergo the full penalty of the 
 law in the same way as persons with normal sexual feel- 
 ing convicted of pederasty. 
 
 Although treatment of contrary sexual feeling does 
 hardly come into consideration, the patients may be given 
 some useful advice. They may derive some benefit from 
 an emphatic representation of the dangers of infection, 
 theft, and robbery with which they are threatened by 
 indulgence in their vice as much as, or even more than, 
 men seeking the company of female prostitutes. They 
 may heed the warning when they are shown how their 
 devotion to male prostitutes is apt to expose them to the 
 vilest sort of blackmail. For pederasty being treated as 
 a serious crime, the male prostitutes make use of this 
 penal statute to practice ruthless extortion upon their 
 unfortunate victims. 
 
 If the patient would not listen to the warnings of 
 his physician, the only advice he can give him is to settle 
 in a State in which pederasty is not considered a punish- 
 able offense. 
 
 In some States in which pederasty is prohibited the 
 Penal Code does not provide punishment for inchastity 
 between men when no imitatio coitus has taken place. 
 The penalty is more rigorous in those cases in which 
 pederasty has been practiced on individuals under a cer- 
 tain age. It is further very severe when the defendant 
 has satisfied his unnatural desire with an individual to 
 whom he stands in an educational relation, being his 
 guardian or his teacher, etc. 
 
 In forensic proceedings dealing with sexual per- 
 versity it is important to demonstrate that the defendants 
 
214 PSYCHE 
 
 are suffering from defective sexual feeling, as in this case 
 the court would grant clemency. It is, therefore, useful 
 to know that men affected with contrary sexual feeling 
 address their male paramours by female pet names in 
 speech as well as in writing. For the public prosecutor 
 may try to refute the defendant's plea of contrary sexual 
 feeling on the ground that his letters containing female 
 names prove that he has kept up amatory relations with 
 women. 
 
 The following case is interesting. A man affected 
 with contrary sexual feeling married a woman and even 
 begot children with her. Later he had to appear in court 
 to answer for pederasty. The prosecuting attorney ob- 
 jected to the plea of contrary sexual feeling, adducing 
 the fact that the defendant had even been able to beget 
 children. Thereupon the defendant alleged that he 
 had married a woman whose appearance was strongly 
 masculine, and that he had succeeded to practice cohabi- 
 tation by intensely thinking of a male paramour during 
 the act. The court accepted the defense and granted 
 clemency. 
 
 Chapter LXXXVII. 
 CRETINISM. 
 
 Cretinism has been defined as endemic idiocy. But 
 idiocy occurs endemically, and yet the patients cannot 
 justly be called cretins. Virchow amplified, therefore, 
 the above definition by designating cretinism as endemic 
 idiocy based on territorial factors, i. e., on conditions of 
 the soil prevailing in a certain region. There are many 
 causes for idiocy other than those which directly depend 
 
SPECIAL PATHOLOGY 215 
 
 upon the territory in which the idiotic children are born 
 and reared. Some children become idiots owing to their 
 descent from debauched, insane, or alcoholic parents, or 
 owing to injuries received at birth, to insufficient nutri- 
 tion in infancy, to severe infectious diseases. These etio- 
 logical factors have little to do with the soil of the terri- 
 tory. They may be comprised under the term social, 
 because they depend largely upon the character and habits 
 of the parents or the customs of the population. But it 
 has been observed that families in which these causes 
 could not be established, and in which healthy children 
 had been born, brought idiotic children into the world 
 after they had transferred their domicile into certain 
 regions, and having removed from these regions, pro- 
 duced anew healthy children. The idiocy must, therefore, 
 have had a territorial cause. Localities in which cretinism 
 is endemic are met with in Switzerland, in the Pyrenees, 
 in the Spessart mountains, etc. 
 
 In former times the cretins were regarded as satanic 
 prodigies, coming from the union of the devil with a 
 human female. The superstition also prevailed that the 
 devil would change healthy children, leaving monsters in 
 the cribs after stealing the children — ''changeling," 
 "Wechselbalg." Nowadays we have to look for a natural 
 explanation. Since cretins are very frequently affected 
 with goitre, i. e., enlargement and degeneration of the 
 thyroid gland, the assumption of a causative relation be- 
 tween defectiveness of this organ and cretinism is not 
 unjustified. This assumption is corroborated by the ob- 
 servation that patients who have lost the thyroid gland 
 through an operation pass into a state resembling cretin- 
 ism. It appears, therefore, plausible that pathological 
 alteration of the thyroid gland would have the same 
 
21.6 PSYCHE 
 
 effect as its extirpation through an operation. Kocher 
 arrived at this conclusion and considered cretinism a 
 cachexia strumipriva existing since early childhood. 
 
 There is no more hideous and horrible aspect of a 
 human being than the one presented by the cretin. The 
 skull is deformed, asymmetrical, the root of the nose is 
 deeply constricted, the upper jaw protrudes considerably 
 — prognathism (p. 1 1 1 ) — the skin, consisting of an excess 
 of fatty and oedematous tissue, exhibits, especially on 
 the face, a peculiar offensive appearance — myxoedema. 
 The unsightliness of the cretin is still more enhanced by 
 a large goitre. The general growth of the body is re- 
 duced — nanism, dwarfishness. The genital organs show 
 faulty development. Besides these somatic anomalies, 
 cretinism is characterized by dementia of a high degree. 
 In the worst cases the dementia is so great that the pa- 
 tients are unable to keep themselves clean, to take food, 
 to learn to speak a word, etc. 
 
 The answer to the question how the deformities of 
 the skull and the constriction of the nasal root are 
 brought about, may help to explain the immediate cause 
 of cretinism. Virchow teaches that in cretins the base of 
 the skull is too short, having undergone premature arrest 
 of development, while the rest of the skull has continued 
 to grow. The constriction of the nasal root is the result 
 of the shortening of the base of the skull. The growth 
 of the skull takes place chiefly at the synchondroses in- 
 tersphenoidalis and sphenooccipitalis. The shortening of 
 the cranial base is due, according to Virchow, to prema- 
 ture synostosis of these two synchondroses. And, indeed, 
 he succeeded to demonstrate an ossification of these places 
 in the skull of new-born cretins. This finding establishes 
 his theory incontestably. The cause of this premature 
 
SPFXIAL PATHOLOGY 217 
 
 ossification probably lies in a pathological alteration of 
 the thyroid gland, produced by unknown territorial fac- 
 tors. The faulty growth of the skull leads to develop- 
 mental disturbances of the brain which cause cretinism. 
 
 To cure the surgical cachexia strumipriva the at- 
 tempt has been made to introduce into the system the 
 active principle of the thyroid gland of which the system 
 had been deprived by the extirpation of the gland. The 
 patients were fed with the thyroid gland of the sheep, and 
 this with some good result. It is, therefore, advisable to 
 try such therapeutic measures also in cretinism. 
 
 The best way for the State to prevent cretinism is 
 to urge and help the inhabitants of the regions in which 
 the disease is endemic to settle in other localities. 
 
SECTION III. 
 DIATHESES OF INSANITY 
 
 Chapter LXXXVIII. 
 
 HEREDITARY PREDISPOSITION TO INSANITY, 
 HEREDITARY INSANITY. 
 
 Hereditary predisposition to insanity consists in 
 diminished power of resistance of the whole organism, 
 and especially of the central nervous system. Individuals 
 affected with hereditary predisposition to insanity are 
 liable to contract psychoses even in consequence of phy- 
 siological processes. When the hereditary predisposition 
 is intense, feeble-mindedness may appear already in in- 
 fancy. When it is of a slighter degree, the sanity may 
 not suffer any harm until puberty. With the oncoming 
 of puberty certain physiological processes take place in 
 the system causing a state of unrest and disturbed mental 
 equilibrium. Systemic alterations which have no injuri- 
 ous effects on persons free from hereditary taint beyond 
 causing a transitory state of uneasiness and increased 
 excitability, call forth psychoses in those affected with 
 hereditary predisposition. The systemic disturbances of 
 puberty affect adolescents having no hereditary predispo- 
 sition to insanity only in a slight measure, but may pro- 
 duce psychoses in individuals whose power of resistance 
 is reduced through heredity. If they are fortunate 
 enough to pass this precarious period without harm to 
 their mental health, disorders of the mind may appear in 
 
SPECIAL PATHOLOGY 219 
 
 consequence of other physiological perturbations occur- 
 ring at a later age. Thus women with hereditary predis- 
 position to insanity may become mentally ill during preg- 
 nancy, and more so during puerperium and lactation. 
 
 Hereditary insanity, therefore, has this characteris- 
 tic feature that it may be brought about even by physio- 
 logical processes. It is further marked by a favorable 
 prognosis of the first attack. The first psychosis on a 
 hereditary basis is of short duration, and complete recov- 
 ery usually ensues. But since the nervous system of one 
 who has gone through a phychosis is anything but 
 strengthened or rendered immune against mental disease, 
 patients with hereditary predisposition to insanity are 
 subject to repeated psychopathic attacks. A third char- 
 acteristic of hereditary insanity, therefore, consists in fre- 
 quent relapses. Recurring hereditary insanity shows the 
 periodic or the circular character (p. 126). In the first 
 case the same clinical picture of mental disease is repeated 
 after a period of well-being, in the second case different 
 clinical pictures alternate. The prognosis of recurrent 
 hereditary insanity is very unfavorable. The patients 
 finally pass into a state of permanent feeble-mindedness, 
 of dementia (Ch. 78, p. 189). 
 
 Chapter LXXXIX. 
 HYSTERICAL INSANITY. 
 
 A frequent foundation for insanity is supplied by the 
 neuroses, among which hysteria takes a prominent place. 
 
 The mental constitution of hysterical individuals 
 differs distinctly from that of normal persons, yet they 
 are not to be regarded as insane. But in many instances 
 
220 PSYCHE 
 
 the hysteria is of such intensity that the patients are fit 
 subjects for the insane asylum. 
 
 The chief characteristics of hysteria consist in ex- 
 traordinary irritabiHty and in frequent and sudden fluc- 
 tuations of the emotions. The hysterical patients confirm 
 the poet's words: "Himmelhoch jauchzend, zum Tode 
 betriibt." From the greatest cheerfulness they may 
 quickly pass into such despondency as to harbor ideas of 
 suicide. Another trait of the hysterical character is ex- 
 treme egotism. Hysterical patients are inconsiderate of 
 others. Behind the mask of charity, self-sacrifice, and all 
 the other virtues they practice is hidden excessive love of 
 self. They are charitable to be attractive, self-sacrificing 
 to be interesting, and perform all kinds of extraordinary 
 acts to excite the attention of relatives and neighbors. 
 Some hysterical patients refuse food, or open their ar- 
 teries by biting, or do not leave their bed for months, etc., 
 in order to awaken interest and sympathy. 
 
 The great sensitiveness of hysterical patients may 
 become the source of hallucinations. When the latter 
 supervene, the picture of a pronounced psychosis is com- 
 pleted. Hysterical insanity, in a way, represents the 
 intensification of the characteristics of hysteria. 
 
 The clinical pictures of hysterical insanity are mani- 
 fold. Some patients are laboring under raving agitation, 
 the sexual factor playing a prominent part. Women suf- 
 fering from hysterical insanity display great irritability 
 and repugnance towards individuals of their own sex, but 
 are friendly and even obtrusive towards men. The 
 vehement excitement of the insane hysterical patient dis- 
 appears very rapidly. To-day she is in the greatest rest- 
 lessness, tears her clothes, dishevels her hair, soils her 
 face ; to-morrow she is in her gala-costume. 
 
SPECIAL PATHOLOGY 221 
 
 Hysterical insanity may appear in the form of para- 
 noia with hallucinations and delusions of grievance and 
 furtherance. 
 
 Melancholic excitement, or better, raptus melancho- 
 licus, is not infrequent in hysterical insanity. There may 
 be an external cause for the melancholic depression, but 
 it is out of proportion to, and entirely insufficient to ex- 
 plain, the intensity of the depression. The melancholic 
 fit passes away in a few days. For it is peculiar of hys- 
 terical insanity that the emotional attitude changes very 
 rapidly. 
 
 Hysterical insanity sometimes presents the picture 
 of delirium appearing in spells during which conscious- 
 ness is more or less disturbed. 
 
 The prognosis of hysterical insanity is favorable as 
 to recovery from an individual attack, but unfavorable 
 regarding the recurrence of mental disorder. An attack 
 that has been preceded by many others may result in per- 
 manent dementia. 
 
 Patients suffering from hysterical insanity may 
 come into conflict with the Penal Code and are liable to 
 be held responsible for their wrong actions, the more so 
 as they create the impression of being sane and even in- 
 telligent. Female patients become implicated in affairs 
 of blackmail having a sexual background. A hysterical 
 patient, for instance, calls on a man in high position, and 
 having been admitted to his presence all alone she accuses 
 him of improper conduct towards her. A prominent 
 psychiatrist relates a case in which a rich hysterical 
 woman had sacrificed her whole fortune for a church, 
 and then committed embezzlement to be able to continue 
 playing the interesting role of patron of a divine institu- 
 tion. 
 
222 PSYCHE 
 
 Chapter XC. 
 PHRENASTHENIA, PSYCHASTHENIA. 
 
 Neurasthenia is another neurosis on which mental 
 disorders are frequently based. The patients lack psychi- 
 cal stability, so that unusual strain and untoward circum- 
 stances and events easily upset their mental equilibrium. 
 The patients not being insane in the true sense of the 
 word, their morbid mental condition might more appro- 
 priately be designated as phrenasthenia, psychasthenia, 
 than as insanity. 
 
 The predisposing cause of phrenasthenia lies in an 
 inherited neuropathy or weakness of the nervous system. 
 The exciting cause is furnished by infectious diseases, 
 shock, mental and physical overexertion, alcoholic ex- 
 cesses, etc. 
 
 The symptoms of phrenasthenia are founded on a 
 defect of inhibition which renders the patients unable to 
 control their ideas, emotions, and impulses. The main 
 symptoms are aboulia (p. yy), compulsory ideas, phobias, 
 doubts (Ch. 35, p. 68), imperative impulses (Ch. 42, 
 p. 86). One of these symptom groups may predom- 
 inate and thus impart its peculiar character to the clinical 
 picture. In this way phobic, doubting, impulsive phren- 
 asthenia may be distinguished. Sometimes phrenasthenia 
 resembles paranoia with delusions of grievance, in other 
 instances depression and anxiety prevail so that the pa- 
 tients appear to be suffering from melancholia. In long 
 standing cases the compulsory ideas may give rise to 
 hallucinations. Phrenasthenia ma}^ have the hypochon- 
 driacal character, the patients believing to be affected 
 with all kinds of physical ailments, such as a defect of 
 
SPECIAL PATHOLOGY 223 
 
 the heart, ulcer of the stomach, tumor of the Hver, soften- 
 ing of the brain, etc. 
 
 The phrenasthenic patient is well aware that his 
 mental condition is morbid. This insight into the disease 
 (pp. 128, 129), which contributes to the distinction of 
 phrenasthenia from true insanity, adds to the suffering of 
 the patient. It keeps him in constant fear of becoming a 
 victim of lunacy. To avert this fate he looks everywhere 
 for help. He consults one physician after another, and 
 is dissatisfied with, and denounces all of them when they 
 fail to relieve him from his worries, fears, compulsory 
 ideas, hallucinations, etc. 
 
 Somatically the patients decline a good deal. They 
 lose weight and emaciate, owing to impairment of sleep, 
 appetite, and digestion. 
 
 The prognosis of phrenasthenia is favorable. Even 
 when an attack has lasted one or two years, complete 
 recovery takes place. But since the neuropathic disposi- 
 tion subsists after the first attack, at least in the same in- 
 tensity as before, the patients are subject to repeated at- 
 tacks of mental disorder. Phrenasthenia as such does 
 not lead to dementia. But true insanity may develop on 
 the neurasthenic basic, and then it depends upon the 
 severity of the case whether or not permanent feeble- 
 mindedness results from the psychosis. 
 
 The treatment of phrenasthenia consists chiefly in 
 physical and mental rest which is best procured by re- 
 moving the patient from his accustomed surroundings 
 and placing him into a proper sanitarium. Nutritious 
 food and tonics are helpful, 
 
224 PSYCHE 
 
 Chapter XCI. 
 DEMENTIA PRAECOX. 
 
 While the mental diseases treated in the preceding 
 chapters seldom lead to intellectual enfeeblement, to de- 
 mentia, there are several forms of constitutional psy- 
 choses, occurring chiefly at the ages of puberty and 
 adolescence, which are characterized by a progressive in- 
 tellectual deterioration resulting in permanent dementia. 
 Indications of this impairment of intelligence being 
 noticeable as early as the initial stage, these psychoses, 
 though differing considerably in their clinical pictures, 
 have been comprised under the general term dementia 
 praecox. The histological examination of the cerebral 
 cortex in these psychoses reveals a definite pathological 
 process involving the microscopical cortical elements. In 
 other constitutional psychoses, however, the pathologic- 
 anatomic finding is negative. 
 
 The most important etiological factor of dementia 
 praecox consists in a hereditary taint. It can be demon- 
 strated in the majority of the cases, according to some 
 authors in 75 per cent. The exciting causes are the same 
 as in other forms of insanity, namely infectious diseases, 
 physical and mental overexertion, fright, shock, excesses, 
 and physiological perturbations of the system. Autoin- 
 toxication has also been adduced as a causative factor. 
 
 Symptoms. If»v childhood the patients frequently 
 exhibit various eccentricities. About the time of puberty 
 pronounced psychopathological features make their ap- 
 pearance. 
 
 A characteristic early symptom of dementia praecox 
 is the impairment of the affective sphere, commencing 
 
SPECIAL PATHOLOGY 225 
 
 with the disappearance of the finer affective tones. The 
 patient becomes Hstless, neglectful of his own person and 
 indifferent to friends and relatives, and loses all ambition. 
 His countenance often bears a dull expression which is at 
 times changed into a silly smile that soon disappears. In 
 the later stages the affective sphere is entirely desolated 
 (Ch. 17, p. 36). The usual affective state of indifference 
 and apathy is sometimes interrupted by periods of irri- 
 tability during which impulsive outbreaks occur. 
 
 The ideational sphere is frequently marked by delu- 
 sions. They usually bear the stamp of absurdity (p. 55) 
 and are strengthened by hallucinations, especially of hear- 
 ing. The association of ideas is inordinate. In conver- 
 sation the patient would jump from one thing to another 
 entirely disconnected. The whole ideational process is 
 characterized by desultoriness. The natural congruity 
 between the ideational contents and the affective state is 
 wanting. The patient, for instance, would manifest 
 cheerfulness while affirming to be depressed or he would 
 wxep at a joyous idea arising in his consciousness — para- 
 mimia (Ch. 39, p. 81). 
 
 The power of memory diminishes gradually. For 
 remote events it remains fairly well preserved for a long 
 time. Deficiency of memory concerning recent occur- 
 rences is noticeable already at an early stage. Sometimes 
 •the failure of memory is surprising. The patient would 
 state correctly his age, year and date of his birth, but 
 would be unable to recall his name. 
 
 Disturbances of the volitional activity form a prom- 
 inent feature of dementia praecox. Various inordinate 
 and purposeless movements indicate the deterioration of 
 the will power. Tics, i. e., queer, abrupt movements of 
 muscles or muscle groups, especially of face, neck, and 
 
226 PSYCHE 
 
 upper limbs, are frequently observed in the precocious 
 dements (Ch. 38, p. 79). Often the patients exhibit 
 stereotypy, verbigeration, mannerism. They remain in 
 one posture or repeat the same movement for any length 
 of time. They eat, speak, and walk in a peculiar affected 
 manner. They use high-sounding, outlandish words and 
 reiterate the same phrase many times. Sometimes they 
 speak and write in doggerels, the style of which is foolish 
 and bombastic. In advanced stages the patients jabber 
 for hours and days, repeating senseless words and syl- 
 lables over and over again. 
 
 The abnormal motor phenomena mentioned above 
 are frequently associated with negativism, i. e., non- 
 sensical resistance to every influence (Ch. 40, p. 82). 
 The patient recedes when a friend approaches him. He 
 hides in a corner, in a closet, or under the bed when the 
 physician calls on him. He declines to fulfill the most 
 reasonable request, and even does just the opposite of 
 what he is asked to do. When requested to show his 
 tongue, he presses his teeth together. He even does not 
 comply with his physical needs, refusing to take nour- 
 ishment, to void urine, or to evacuate his bowels. 
 
 Hypersuggestibility is another defect of volition met 
 with in dementia praecox, sometimes together with neg- 
 ativism (Ch. 40, p. 82). The patient responds too read- 
 ily to incidental influences. The slightest stimulus may 
 call forth a reaction, many movements thus appearing to 
 ensue automatically. Imitation of actions seen, echo- 
 praxia, and repetition of words and phrases heard, echo- 
 lalia, result from this impairment of the will power. 
 
 The psychomotor response of the precocious dement 
 is slow. When a question is put to him, a few seconds 
 may elapse before he makes an attempt to answer it. 
 
SPECIAL PATHOLOGY 227 
 
 Sometimes the precocious dement is unable to answer 
 in a direct manner the simplest questions. He begins to 
 reply, but incidental ideas deflect his train of thought, 
 rendering the answer entirely irrelevant — paralogia, 
 "Vorbeireden" (p. 83). 
 
 Finally, volitional disturbance is manifested by lack 
 of self-control. The occasional emotional outbursts lead 
 to violent acts. In a fit of rage the patient may tear his 
 clothes, break furniture, assault anybody crossing his 
 way, etc. 
 
 The power of understanding shows a progressive 
 deterioration. This characteristic symptom of dementia 
 praecox is noticeable from the inception of the disease. 
 As the latter advances the .patient becomes more and 
 more stupid, his speech nonsensical, incoherrent. In the 
 last stages his utterances form a foolish medley of words, 
 a word-salad ("Wortsalat"). Deficiency of the power of 
 understanding constitutes a prominent feature of demen- 
 tia praecox in all its stages. 
 
 Consciousness is usually clear and orientation is, 
 as a rule, little disturbed. In spells of great excite- 
 ment the consciousness is somewhat clouded. Stuporous 
 conditions (Ch. ']2, p. 159) are frequent in dementia 
 praecox. They are characterized mainly by disturbance 
 of consciousness and volition. 
 
 Certain physical symptoms frequently met with in 
 dementia praecox may be of diagnostic value. Apoplec- 
 tiform and epileptiform attacks occur in this disease in 
 the same way as in paretic insanity (pp. 251, 255). The 
 apoplectiform attacks are sometimes followed by para- 
 lyses. Certain convulsive movements are quite character- 
 istic of dementia praecox, as the spasmodic distortions 
 of the mouth (p. 80), rolling of the eyes, wrinkling of 
 
228 . PSYCHE 
 
 the forehead, etc. These motor disturbances may have 
 some relation to the increased irritabihty of the muscles, 
 not infrequently observed in the precocious dements. A 
 slight mechanical irritation of a muscle calls forth a long 
 lasting contraction which is visible as a tumor over the 
 muscle, the so-called idiomuscular swelling. Tremor is 
 often present. The tendon reflexes are usually increased. 
 The pupils are often dilated and show great mobility 
 which may amount to a pronounced hippiis. Vasomotor 
 disturbances, such as cyanosis, local oedema, dermo- 
 graphy, are frequently seen. At times there is profuse 
 perspiration. Exophthalmic goitre is not rare in demen- 
 tia praecox. 
 
 Dementia praecox appears in three forms, the hebe- 
 phrenic, catatonic, and paranoiic. No symptom belongs 
 exclusively to one form. The division is based rather 
 upon certain symptoms being more prominent in one form 
 than in the other. 
 
 Hebephrenic Form. The hebephrenic form of 
 dementia praecox has a prodromal stage of a few years 
 marked by neurasthenic and hypochondriacal symptoms 
 and occasional spontaneous outbursts of temper. The 
 inception of pronounced psychopathic manifestations is 
 slow. This is one of the features which distinguish the 
 hebephrenic from the catatonic form. 
 
 The hebephrenic form has been divided into two 
 groups, dementia simplex and hebephrenia proper. The 
 difference between the two consists chiefly in dementia 
 simplex running a more protracted course and having 
 less often periods of excitement than hebephrenia proper. 
 
 Dementia simplex is characterized by general apathy 
 and a slowly progressing intellectual enfeeblement. The 
 latter sometimes reaches but a moderate degree and then 
 
SPECIAL PATHOLOGY 229 
 
 the disease is arrested. Precocious dements of this sort 
 are found among ragamuffins and vagabonds, which is 
 forensically of great importance. In the majority of 
 cases the disease progresses until the patients become 
 helpless mental wrecks. Impulsive outbreaks, delusions, 
 stereotypy, stupor, etc., do occur, but are comparatively 
 rare. 
 
 In hebephrenia proper, on the other hand, excitative 
 states are more frequent and of longer duration. Hallu- 
 cinations and delusions are more marked, although they 
 do not form as prominent a feature as in other forms of 
 dementia praecox. In the early stages the delusions are 
 of a depressive and persecutory character. The patient 
 believes everybody to harbor inimical designs against 
 him. Later the delusions are expansive in nature. The 
 impulsive outbreaks and the delusions may lead to violent 
 acts. Disturbances of volition, such as automatism, 
 stereotypy, mannerism, negativism, etc., are seen quite 
 often. Hebephrenia proper finally passes into a stage of 
 permanent dementia. 
 
 Catatonic Form. The catatonic form of dementia 
 praecox differs from the hebephrenic form through a 
 more acute onset and through more frequent states of 
 excitement and stupor. Hallucinations and delusions are 
 also somewhat more conspicuous in the catatonic form 
 than in hebephrenia. 
 
 After a period in which neurasthenic and hypochon- 
 driacal symptoms prevail, the mental disorder begins sub- 
 acutely with anxiety and depression and presents for 
 some time a clinical picture resembling melancholia. 
 Now and then the patient utters delusions of a perse- 
 cutory character. Owing to the depression, a state of 
 mutism may persist for days, weeks, and months. At 
 
230 PSYCHE 
 
 times the depression is interrupted by impulsive outbreaks 
 driving the patient to violent acts. Suicidal attempts are 
 not rare in this stage. The depressive stage is followed 
 by a period of excitement marked by hallucinations, delu- 
 sions, and frequent explosions of violence. In such spells 
 the patient displays destructiveness, aggressiveness, and a 
 homicidal tendency. This period is succeeded by a stage 
 of catatonia or stupor with catalepsy. Excitative and 
 stuporous states alternate several times and finally the 
 patient passes into a state of permanent dementia. 
 
 In many cases the sequence of the stages is different 
 from the one just outlined. The stage of depression may 
 be followed by stupor or after the preliminary neuras- 
 thenic symptoms the mental disease may set in with 
 stupor. 
 
 The stupor varies greatly in duration and intensity. 
 It may last a few hours or several months. There may 
 be complete loss of consciousness and great rigidity of 
 the muscles, or the consciousness is little disturbed, and 
 there is only a general apathy associated with moderate 
 muscular tension. In the stuporous conditions with but 
 slight impairment of consciousness disturbances of voli- 
 tion, such as stereotypy, verbigeration, mannerism, neg- 
 ativism, automatism, and hypersuggestibility are quite 
 frequent. 
 
 Paranoiic Form. In the paranoiic form of demen- 
 tia praecox delusions form a predominant feature. They 
 persist for years while in the other forms they tend to 
 evanesce in a comparatively short time. 
 
 This form may be distinguished into two groups. 
 In the first one, dementia paranoides (Kraepelin), indi- 
 cations of intellectual enfeeblement appear early and pro- 
 nounced dementia develops quite rapidly. The delusions 
 
SPECIAL PATHOLOGY 231 
 
 in this group are changeable, nonsensical, incoherent, 
 lacking system. In the second group, however, the delu- 
 sions are more stable and coherent and systematized (Ch. 
 29, p. 58) for several years; then they become confused 
 and fade away leaving a moderate dementia. 
 
 In the early stages of the paranoiic form the affec- 
 tive state is that of depression and anxiety, and the delu- 
 sions have a persecutory character. Later the mood is 
 rather joyous, exalted, and the delusions are of a cheerful 
 nature. At times great irritability prevails, giving rise 
 to impulsive outbreaks. 
 
 The conduct of the patient is in conformity with his 
 delusions. In the depressive stage he is reserved, , cau- 
 tious, suspicious. In the stage of exaltation he is rather 
 loquacious and dresses himself up in gaudy attire. While 
 in a mood of irritability he may be violent. 
 
 Stupor occurs but seldom in the paranoiic form. 
 Stereotypy and negativism, however, are not rare, and 
 mannerism in eating, speaking, walking, etc., is fre- 
 quently observed. 
 
 Course and Prognosis of Dementia Praecox. 
 The course of dementia praecox, from the first appear- 
 ance of pronounced psychopathological symptoms until 
 the beginning of the final stage of permanent dementia, 
 extends over several years. Remissions occur lasting in 
 some instances many years. The progress of the disease 
 may be arrested at a certain stage. This is especially the 
 case in the hebephrenic form. Fatal termination is 
 usually due to an intervening disease, such as tubercu- 
 losis, to which especially stuporous patients are frequently 
 subject. Eight per cent, of hebephrenic and 13 per cent, 
 of catatonic patients get well to the extent of being fit 
 for useful occupation. But even in such cases a closer 
 
232 PSYCHE 
 
 examination reveals mental defects. Restitutio ad in- 
 tegrum, if it occurs at all, is very rare. 
 
 Differential Diagnosis of Dementia Praecox. 
 In dementia praecox there are indications of an impair- 
 ment of the reasoning power even at the onset of the 
 psychosis. This point in connection with the youthful 
 age of the patient is almost pathognomonic. There is 
 only one other form of insanity in which signs of en- 
 feeblement of the intellect are present as early as the 
 initial stage, namely paretic insanity (p. 248). In gen- 
 eral the diagnosis must be based on the entire clinical 
 picture. In the early stages dementia praecox resembles 
 phrenasthenia (Ch. 90, p. 222), from which it is distin- 
 guished by the emotional apathy, by the slow psycho- 
 motor response, and by indications of intellectual de- 
 terioration, of mannerism, and of other motor anomalies. 
 The depression of dementia praecox differs from melan- 
 cholia by the character of the accompanying delusions. 
 The characteristic melancholic ideas of sinfulness are 
 missing in dementia praecox. The states of excitement 
 and restlessness in dementia praecox are not uniform and 
 steady, but moments of quiet and apathy intervene, while 
 in mania the agitation is constant and associated with the 
 characteristic cheerfulness. In dementia praecox the 
 pupillary reaction is lively and motor defects of speech 
 and of writing and other pareses are missing, in contra- 
 distinction to paretic insanity, which is characterized by 
 such motor disturbances. In the paranoiic form of de- 
 mentia praecox there are early indications of impairment 
 of the intellect and the delusions are marked by ab- 
 surdity. In true paranoia, however, the reasoning power 
 remains unabated for a long time, and the delusions are 
 fairly well accounted for. 
 
SPECIAL PATHOLOGY 233 
 
 Therapy. The treatment of dementia praecox is 
 chiefly preventative. Children from psychopathic fam- 
 ihes should not be overexerted either physically or men- 
 tally. They should be brought up to observe regularity 
 of habits and to avoid all kinds of excesses. They should 
 not be allowed to drink alcohol and to smoke tobacco. 
 Especially masturbation must be prevented. Patients suf- 
 fering from dementia praecox should be removed from 
 their home surroundings and put into a psychopathic hos- 
 pital where they can be best taken care of. Only very 
 mild cases may be treated at home. 
 
 Chapter XCII. 
 
 RECURRENT INSANITY, MANIC=DEPRESSIVE 
 INSANITY. 
 
 F. H. V. Grashey in his wonderfully lucid lectures on 
 psychiatry never spoke of manic-depressive insanity. 
 Only occasionally he touched upon periodic and circular 
 insanity which other authors range with a large class of 
 psychoses designated as manic-depressive insanity. Al- 
 though this treatise conforms quite exactly with the teach- 
 ings of V. Grashey, it seems advisable to discuss briefly 
 this class of mental diseases, as the views of those authors 
 have received wide recognition. 
 
 The clinical picture of melancholia (p. 154) is com- 
 posed of three cardinal symptoms, namely : i ) depressed 
 affective state or sad mood ("traurige Verstimmvmg," 
 p. 31) ; 2) dearth of ideas and retardation of the idea- 
 tional process (p. 41) ; 3) diminished frequency of voli- 
 tional manifestations (p. 78). For the sake of brevity 
 
234 PSYCHE 
 
 these three symptoms may be called respectively: dejec- 
 tion, immobility of thought, inactivity. It will be more 
 conducive to clearness to avoid in this discussion the term 
 depression for the reason that it does not refer to mood 
 alone, but also to other mental states which may be de- 
 pressed, while dejection usually implies the affective state 
 only. 
 
 According to v. Grashey immobility of thought and 
 inactivity are not independent from dejection, but con- 
 ditioned by it so that wherever the latter symptom is 
 present we will always meet with the other two symptoms 
 (Ch. 14, p. 33). A sad patient is quiet, and his thoughts 
 are sluggish. Only when the dejection becomes increased 
 to anxiety and fear the inactivity gives way to restless- 
 ness. Apparently the patient then produces also more 
 ideas. In reality, however, it is one and the same appre- 
 hensive idea that always returns, keeping up the restless- 
 ness (pp. s^, 34). 
 
 The opposite of melancholia is mania, the clinical 
 picture of which is founded on the three cardinal symp- 
 toms : i) exalted affected state or cheerful mood ('liei- 
 tere Verstimmung," p. 36) ; 2) abundance of ideas and 
 acceleration of the ideational process (p. 42); 3) in- 
 creased frequency of volitional manifestations (p. 78). 
 These three symptoms may be called respectively : exalta- 
 tion, mobility of thought, activity. The term "flight of 
 ideas" (pp. 36, 42), often used for the second symptom, 
 will more appropriately be reserved for the highest de- 
 grees of the symptom. 
 
 In mania there is the same relation between the three 
 cardinal symptoms as in melancholia. They are not co- 
 ordinate, but from exaltation necessarily result mobility 
 of thought and activity (Ch. 16, p. 35). In a fit of 
 
SPECIAL PATHOLOGY 235 
 
 anger, however, due to resistance and obstacles (p. 163) 
 or to hallucinations contrary to the patient's delusions 
 (p. 166), his cheerful mood may not be obvious, so that 
 there are apparently mobility of thought and activity 
 without exaltation. The wrathful mood may even be 
 mistaken for dejection. 
 
 The hypothesis explaining the influence of the affect- 
 ive state upon the ideational process (Ch. 8, p. 19), and 
 at the same time the manic and melancholic syndromes, 
 is supported by pathological as well as normal phenomena. 
 The association of dejection, immobility of thought, in- 
 activity on one side, and of exaltation, mobility of 
 thought, activity on the other side, forms the rule not 
 only in patients, but also in sane individuals. In a sad 
 mood we have difficulty in thinking and prefer to be 
 quiet, our thoughts flow readily, and we are lively and 
 active in a cheerful frame of mind. 
 
 The foregoing explanation of mania and melancholia will 
 hardly agree with Kraepelin's views on manic-depressive insanity. 
 According to this author every mania and almost every melancholia, 
 as defined before, constitute different phases of one and the same 
 disease, which is characterized by repeated attacks of mania, or of 
 melancholia, or of mixed states in which the cardinal manic and 
 melancholic symptoms are combined. From the three pairs of 
 opposite symptoms would result eight different forms. Starting 
 from mania, composed of exaltation, mobility of thought, and 
 activity, the other seven forms are obtained by replacing one or 
 more of these symptoms by their opposites. The combination of 
 exaltation, mobility of thought, activity, constitutes the manic phase 
 of manic-depressive insanity, and the combination of dejection, 
 immobility of thought, inactivity, forms the depressive phase of 
 manic-depressive insanity. The former does not differ materially 
 from mania (p. 162), and the latter from melancholia (p. 154) 
 as described before in this treatise. 
 
 Considering only those cases of manic-depressive 
 insanity in which the repeated attacks are always purely 
 
236 PSYCHE 
 
 manic or purely melancholic, or alternately sometimes 
 purely manic, at other times purely melancholic in char- 
 acter, the lengthy names of the disease and its attacks 
 may be dispensed with. It has been known long ago 
 that patients may go through many attacks of mania 
 or melancholia and that these clinical pictures may alter- 
 nate (p. 1 68). A patient subject to attacks of mania or 
 melancholia, separated by lucid intervals, suffers from 
 recurrent mania or recurrent melancholia. When the 
 intervals are fairly regular, we speak of periodic mania 
 or melancholia. In circular insanity there are cycles 
 composed of mania, melancholia, and a lucid interval. 
 When the intervals of circular insanity are missing or too 
 short to be perceptible, we have alternating insanity. 
 So far there seems to be no need to abandon the long 
 approved terms mania and melancholia and to replace 
 them by the cumbersome names manic phase of manic- 
 depressive insanity for mania, and depressive phase of 
 manic-depressive insanity for melancholia. We may 
 simply speak of recurrent insanity and have to bear in 
 mind that an attack of mania or melancholia, although 
 it has ended in partial or complete recovery, may be re- 
 peated at some future time in the same or the opposite 
 character, especially if the case gives a history of previous 
 attacks. 
 
 But if there be cogent reasons to regard some attacks of 
 recurrent insanity as truly mixed states, we must acknowledge the 
 modern views on manic-depressive insanity and accept the names 
 for the disease and its single attacks as appropriately selected. 
 The attacks of recurrent insanity very often lack the character of 
 pure mania or pure melancholia, but apparently contain manic and 
 melancholic symptoms at the same time. Indeed, many authors 
 maintain that pure mania is of very rare occurrence. 
 
 Kraepelin assumes that the cardinal manic and melancholic 
 
 iMfU 
 
SPECIAL PATHOLOGY 237 
 
 symptoms may combine in any manner. He thus arrives at six 
 mixed states. 
 
 1. In the manic symptom complex the exaltation may be 
 replaced by a depressed mood. This form is the so-called irascible 
 mania {"sornige Manie"). The patients are constantly in an angry 
 frame of mind and vent their wrath by inveighing against every- 
 body. When the excitement is slight, the picture of nagging mania 
 {"norgelnde Manie") is present, the patients being discontented arid 
 finding fault with everything and everybody. 
 
 2. When in irascible mania mobility of thought is replaced 
 by its opposite, there arises the picture of depressive excitement. 
 The patients display great restlessness. They talk incessantly, tor- 
 menting themselves and others with the same hypochondriacal ideas. 
 
 3. When in depressive excitement the depressed mood gives 
 way to exaltation, there is produced the picture of mania with 
 dearth of ideas ("gedankenarme Manie"). This form is frequently 
 met with. The patients perceive but slowly and inaccurately, do 
 not comprehend questions before they have been repeated several 
 times. They create, therefore, the impression of being weak-minded, 
 though later they may turn out to be quite intelligent. The mental 
 condition of the patients is very fluctuating, so that at times they 
 are adroit and quick at repartee, while at other times they cannot 
 be moved to say a word. The patients are in a cheerful mood and 
 laugh at every trifle. Their talk is incoherent, twaddly, empty. 
 They don't speak much nor hastily. For a long time they may remain 
 silent, if they are not stimulated. In the course of a conversation 
 they are at first unable to find words, but later they may develop 
 a torrent of verbiage. The impulse for movement is limited to 
 grimacing, occasional dancing about, plucking at the hair and the 
 clothes. Some patients conduct themselves orderly and quietly, so 
 that superficial observation would not reveal any excitement. They 
 are in an exalted mood, now and then somewhat irritated, and at 
 times show themselves rude only to burst into merry laughter after 
 a while. Other patients sit around idly, laugh boisterously, and 
 display a tendency to mischievous tricks, such as smearing the 
 walls, plugging up the keyholes, etc., while for useful occupation 
 they are entirely unfit. 
 
 At times violent outbreaks occur in these patients, but they 
 are of short duration. Even genuine mania may appear transitorily. 
 
 4. Cheerful mood may substitute the dejection in the clinical 
 picture of melancholia. The condition then obtained is the so-called 
 manic stupor. The patients are indifferent to their environment, do 
 
238 PSYCHE 
 
 not answer a question, at best they mumble with a low voice in 
 reply. They smile without perceptible cause, lie quietly in bed, 
 fumble with the bed clothing, and decorate themselves phantastically, 
 all this without evident emotional excitement. Sometimes the 
 patients give utterance to delusions of variable contents. Orienta- 
 tion is usually little disturbed. Sometimes catalepsy is observed. 
 Occasionally impulsive outbreaks occur, the patients suddenly be- 
 coming very violent and manifesting a tendency to dangerous acts. 
 At other times they may be quiet, collected, and intelligent, but 
 such a condition does not last very long. Some patients walk about 
 the ward in measured steps and barely speak a word, but utter 
 now and then a witty remark. Frequently the patients remember 
 everything that has occurred, but are unable to explain their strange 
 conduct. 
 
 5. In the clinical picture of melancholia immobility of thought 
 may be replaced by its opposite. The patients are quiet, silent, 
 despondent, yet they exhibit curiosity and interest in their environ- 
 ment. When they break their silence, they relate that many ideas 
 pass through their minds. They read and write a good deal, com- 
 posing long stories which treat of their fears and delusions of sin. 
 
 6. Finally Kraepelin "believes to have observed states which 
 would correspond to the presupposed association of flight of ideas 
 and cheerful mood with phychomotor inhibition." These patients 
 are gay, at times somewhat irritable, distractible, inclined to jokes. 
 When spoken to, they readily start a long rigmarole with flight of 
 ideas and numerous sound associations. Their general behavior, 
 however, is remarkably tranquil. They lie quietly in bed, now and 
 then uttering a remark or laughing. But an inner tension seems to 
 influence the patients, for they frequently become very violent with- 
 out any cause. 
 
 It is diflicult to adjust the theory of the relation between 
 ideational process, volitional activity, and affective state (Ch. 8, p. 19, 
 Ch. 14, p. 33, Ch. 16, p. 36) to these mixed states. For if it be cor- 
 rect that exaltation causes mobility of thought and activity, while 
 dejection produces immobility of thought and inactivity, truly mixed 
 states cannot occur. But perhaps the above mixed states need not 
 be taken as such. Thus "irascible mania" may be considered as pure 
 mania in which the exaltation is hidden by a wrathful mood (pp. 163, 
 166, 235), but not replaced by its opposite, viz., dejection. Similarly 
 "depressive excitement" may be explained as pure melancholia in 
 which the dejection is increased to anxiety and fear, an affective state 
 that causes restlessness — melancholia agitatia (pp. 33, 34, i55)- 
 
SPECIAL PATHOLOGY 239 
 
 In "manic stupor" the affective state is that of indifference; there, 
 is neither genuine exaltation, nor dejection. An occasional smile 
 or witty remark does not necessarily indicate true exaltation. Possi- 
 bly we may detect now and then a sorrowful expression of the 
 countenance, when we observe the patient without preconceived 
 assumption. Casual restlessness is not necessarily manic in nature, 
 but may be due to fear or to hallucinations. 
 
 The occurrence of the mixed state composed of exaltation, 
 mobility of thought, and inactivity is somewhat doubtful yet. 
 
 The two mixed states, namely mania with dearth of ideas 
 {"gedankenarme Manie") and the other one which in contrast may 
 be called melancholia with abundance of idea {"gedankenreiche 
 ' Melancholie") can hardly be brought in conformity with the theory 
 that exaltation produces mobility, and dejection, immobility of 
 thought. If for this reason the theory is to be abandoned, there 
 remains the important question to be answered why normally as 
 well as pathologically exaltation is so often associated with accelera- 
 tion, and dejection with retardation of the ideational process. Until 
 this question will have received a solution with which the modern 
 views on manic-depressive insanity do not conflict, there is good 
 justification in avoiding this misleading designation of the disease 
 and in abiding by the old term recurrent insanity, the more so as 
 Kraepelin himself, the foremost exponent of the theory of manic- 
 depressive insanity, remarks : "Die Lehre von den Mischzustanden 
 ist noch zu unfertig, als dass eine weitergehende Kennzeichnung 
 der einzelnen Formen moglich ware." 
 
 Etiology. Hereditary psychopathic predisposition 
 is so frequently met with in recurrent insanity that the 
 disease may be classed with hereditary insanity which, as 
 has been pointed out before, is characterized by a strong 
 tendency to recur (p. 218). A hereditary taint can be 
 established in 80 per cent, of the cases. The first attack 
 usually occurs before the age of 25 years, but in some 
 instances as early as the tenth, in others as late as the 
 fiftieth year of age. Physiological perturbations of the 
 system may bring on the disease. This is perhaps the 
 reason why it is more frequent among women than 
 among men, the former being more often subject to 
 
240 PSYCHE 
 
 physiological systemic agitations than the latter, at the 
 appearance of the first menses, and during pregnancy, 
 puerperium, lactation, and climacterium. In physiologi- 
 cal disturbances furnishing an exciting cause of the dis- 
 ease lies another hereditary feature (p. 218). The usual 
 exciting causes of insanity, such as shock, fright, worry, 
 excesses, infectious diseases, physical and mental over- 
 exertion, are even more effective in recurrent insanity. 
 
 Course and Prognosis. The disease begins with an 
 attack of melancholia or mania which ends in recovery. 
 The attack is repeated in the same character after a 
 longer or shorter lucid interval. Several uniform at- 
 tacks follow — recurrent (periodic) melancholia or mania. 
 Sometimes an attack unexpectedly presents the opposite 
 character. Only in a small number of cases the disease 
 passes directly from one phase into the other — alterna- 
 ting insanity — or is interrupted after two opposite phases 
 by a lucid interval — circular insanity. The first attack, 
 in the majority of the cases, is of a depressive character, 
 especially in women and in young patients. The depres- 
 sion is followed by a period of well-being, or passes unin- 
 terruptedly into a manic stage which ends in recovery. 
 But if the first attack is manic, it is nearly always fol- 
 lowed by a lucid interval, rarely by a depressive phnse. 
 The so-called mixed states, as a rule, do not occur before 
 several depressive or manic attacks have preceded. 
 
 The duration of the attacks varies from a few days 
 to several years, and that of the lucid intervals from a 
 few days to a great number of years. As a rule the at- 
 tacks last from 6 to 12 months. The early intervals are 
 longer than the later ones. In the intervals the mental 
 condition of the patients is usually normal, or at least 
 appears to be so. But sometimes, especially later in the 
 
SPECIAL PATHOLOGY 241 
 
 disease, there occur in the intervals short periods of 
 moderate exaltation, irritability, and restlessness, or of 
 dejection and inactivity. 
 
 The prognosis of recurrent insanity is favorable 
 with regard to the single attacks, but unfavorable as to 
 recurrence of the disease. The first attacks ordinarily 
 end in complete recovery, but later attacks leave behind 
 some mental enfeeblement. The danger of pronounced 
 mental deterioration, of secondary dementia, is greatest 
 when the attacks are very frequent or prolonged. 
 
 A patient may have an attack of mania or melan- 
 cholia, recover completely, and remain sane all through 
 the rest of his life. Whether such a case is to be classed 
 with recurrent insanity — manic-depressive insanity — or 
 not, is merely a theoretical question. Practically it is 
 of importance that in a given case of mania or melan- 
 cholia with no history of previous attacks the physician 
 should be guarded in the prognosis, bearing in mind 
 the possibility of a recurrence of the disease, especially 
 when a strong hereditary taint can be established in the 
 patient's family. In cases, however, in which there is a 
 history of previous attacks, the physician is undoubtedly 
 dealing with recurrent insanity and may predict other at- 
 tacks with a fair degree of probability. 
 
 Differential Diagnosis. When a history of previ- 
 ous attacks is obtained, the diagnosis offers no difficulty. 
 The disease has to be differentiated from paretic insanity 
 and dementia prgecox, in which psychoses there may also 
 be excitative and depressive stages separated by lucid in- 
 tervals. In recurrent insanity early indications of intel- 
 lectual deterioration are lacking. The delusions are not 
 as absurd in character as in paretic insanity and dementia 
 praecox. In general paresis there are characteristic physi- 
 
242 PSYCHE 
 
 cal symptoms, such as faulty reaction of the pupils, de- 
 fective articulation, etc. Pronounced stereotypy, man- 
 nerism, negativism, automatism, etc., speak rather for 
 dementia prgecox than for recurrent insanity. In the 
 latter disease the patients respond more readily to exter- 
 nal stimuli, and, while in a manic phase, are more tract- 
 able than in the former. Mild forms of manic-depressive 
 insanity may be taken for phrenasthenia. But in this 
 disease the patients have the insight into the morbidity of 
 their mental condition. 
 
 Therapy. Preventative treatment is very important 
 in recurrent insanity. Patients having gone through an 
 attack of mania or melancholia should lead a quiet life, 
 free from any excitation. Marriage is contraindicated 
 in cases of doubtless recurrent insanity. The treatment 
 of the individual attacks has been outlined in the chapters 
 on mania and melancholia. 
 
 Chapter XCIII. 
 EPILEPTIC INSANITY. 
 
 Epilepsy is frequently productive of mental disorder. 
 It leads to insanity in two ways. In the first place, the 
 injurious influence exerted on the mind by the epileptic 
 attacks causes mental deterioration. Secondly, the epi- 
 leptic attacks are sometimes replaced by spells of mental 
 alienation, the so-called psychic equivalents of the epileptic 
 attacks. 
 
 The first form of epileptic insanity appears as 
 feeble-mindedness. Shortly after every epileptic attack 
 the patient has difficulty in remembering things and 
 
SPECIAL PATHOLOGY 243 
 
 events, and this disturbance of memory is associated with 
 some impairment of the understanding. This state of 
 mental weakness is transitory. But when the attacks recur 
 frequently, it becomes permanent and represents epileptic 
 insanity in the form of feeble-mindedness. 
 
 Regarding the psychic equivalents of the epileptic 
 attacks, preepileptic insanity and postepileptic insanity are 
 distinguished. An analysis of the epileptic attack will 
 more clearly explain the nature of the psychic equivalent. 
 The epileptic attack may be completely or incompletely 
 developed, and mild as well as severe attacks may occur 
 in the same patient. The typical complete epileptic at- 
 tack begins with the so-called aura, consisting in peculiar 
 sensations which warn the patient of the approach of the 
 next and severer stages of the attack. The patient has 
 still time to retreat to a place of shelter and safety and 
 to put dangerous objects out of the way. The aura is 
 succeeded by feelings of anxiety associated with ter- 
 rifying hallucinations and illusions, as hearing the thun- 
 dering of cannons, seeing burning structures, beholding 
 bitter enemies in people standing near by, etc. Complete 
 loss of consciousness and general convulsions follow 
 thereupon. The patient falls down, and tonic and clonic 
 spasms arise in various muscle groups. The spasms of 
 the respiratory muscles hinder the respiration, causing 
 cyanosis, especially visible on neck and face. The mouth 
 is almost closed, the tongue is caught between the teeth, 
 and the lips become soon covered with foam, the saliva 
 being drawn in and out between them. After a while 
 the convulsions gradually subside and finally cease. The 
 unconsciousness, however, continues for some time and 
 passes into a sleeplike state from which the patient sooner 
 
244 PSYCHE 
 
 or later awakes with no recollection of what has trans- 
 pired. 
 
 These four stages of the epileptic attack are not 
 always well marked. The aura and the stage of anxiety 
 may be very short. The patient has hardly become aware 
 of the preliminary disagreeable sensations when he is 
 seized with the convulsions. Sometimes the attack stops 
 short in a certain stage. Thus the patient, overcome by 
 the unpleasant sensations of the aura, may recover imme- 
 diately. At another time a state of semi-consciousness 
 follows a short aura without the intervention of con- 
 vulsions. 
 
 In the semiconscious state just mentioned the patient 
 is entirely unreliable. Driven by terrifying hallucina- 
 tions, he is apt to commit the greatest atrocities. It may 
 be added here that the homicides perpetrated by the epilep- 
 tics are characterized by extreme brutality and by lack 
 of motive. The semiconsciousness following immediately 
 after a short and imperceptible aura may last very long, 
 several days. It represents a psychic equivalent of the 
 epileptic attack. The abnormal mental condition just 
 sketched constitutes preepileptic insanity. 
 
 Sometimes the attack is developed as far as the stage 
 of convulsions, and after they have ceased, the patient 
 rises too early before having recovered full consciousness, 
 and begins to walk about in a semiconscious condition. 
 The latter may last days and weeks, and during this 
 time the patient may perform all kinds of misdeeds. 
 This mental disorder of the epileptic patient is designated 
 as postepileptic insanity. 
 
 In all exactness the psychic equivalent of the epileptic 
 attack is but a protracted stage of the attack. 
 
 The psychic equivalents of the epileptic attacks oc- 
 
ifiiiw 
 
 SPECIAL PATHOLOGY 245 
 
 cur chiefly in epilepsy commencing after the completion 
 of the general development, i. e., after the age of 20 
 years^ and especially in those cases in which a cranial in- 
 jury has furnished the cause of the epilepsy. 
 
 It is a peculiarity of the epileptic attacks, of the in- 
 complete as well as the complete ones, that they may be 
 brought on through certain sensitive areas of the body. 
 After Brown-Sequard had succeeded in artificially pro- 
 ducing epilepsy in animals, the observation has been made 
 that in man a sensitive scar, especially of the skull, may 
 become the source of epileptic attacks. That the latter 
 are periodic, although the irritative influence of the scar 
 is constant, may be explained in the following way. The 
 sensitive scar increases the excitability of the patient. 
 Any insignificant incidental irritation suffices, therefore, 
 to produce an attack, as a psychical excitement, slight 
 overfilling of the stomach, knocking against an object, etc. 
 
 The treatment of epileptic insanity is symptomatic. 
 Care must be taken that the patients do not harm them- 
 selves and others. The extirpation of a sensitive scar 
 which may form the exciting cause of the epileptic at- 
 tacks, is indicated. The psychic equivalents are very 
 little influenced by the bromides. 
 
 Forensic Consideration. Epileptics are liable to 
 come into conflict with the Penal Code. The physician 
 ought, therefore, to be well informed about the connec- 
 tion between epilepsy and crime, about the fact that epilep- 
 tics are subject to spells of impaired consciousness during 
 which they may commit various misdeeds. When called 
 upon to give an opinion in a case of brutal homicide, 
 unexplained by any motive, the physician should bear 
 in mind that such crimes are characteristic of epilepsy. 
 A helpful hint is obtained when a gap of memory can be 
 
246 PSYCHE 
 
 demonstrated in the defendant (p. 66). For the epileptic 
 attacks and their psychic equivalents leave gaps of mem- 
 ory in the patient. The factor of amnesia ought, there- 
 fore, to receive proper consideration in criminal cases 
 where there is suspicion that the defendant is an epileptic. 
 He may not know anything of the crime accused of, 
 having committed it in a semiconscious state for which 
 there is now a gap of memory. 
 
 An epileptic having committed a punishable act 
 during a semiconscious state may be able to give to the 
 physician an exact description of the details of the of- 
 fense. In such a case the physician should not exclude 
 a disturbance of consciousness for the time of the offense 
 because of the apparent absence of amnesia. For it is 
 possible that the defendant is acquainted with the details 
 of the offense because he has learned them subsequently 
 from others. 
 
 An impostor found guilty of repeated embezzlement, 
 theft, etc., may pretend to have committed these crimes 
 in states of unconsciousness. In such an instance it is 
 necessary to examine whether the unlawful acts have 
 always turned out to the advantage of the perpetrator or 
 have now and then been harmful to him. In the first 
 case malingery is to be assumed, in the second case epi- 
 lepsy is to be taken into consideration. 
 
 Chapter XCIV. 
 PARETIC INSANITY. 
 
 General paresis, general progressive paralysis, stands 
 in close relation to lues, syphilitic patients having a far 
 greater predisposition to paresis than those free from 
 
SPECIAL PATHOLOGY 247 
 
 luetic infection. Nevertheless, some psychiatrists have 
 held the view that paresis does not constitute a late luetic 
 symptom, since in a good many cases lues can positively 
 be excluded (p. 115). 
 
 General paresis is chiefly an acquired disease. It is 
 contracted through excesses in Baccho et Venere and 
 through overexertion. Regarding sexual indulgence the 
 excesses themselves are not as important an exciting 
 cause as the infection which they occasion. 
 
 General paresis occurs most frequently at the age of 
 25 — 40 years. Between 20 — 25 it is uncommon, so that 
 in a case of this age, showing paretic symptoms, lues 
 cerebri, which resembles paresis, has to be taken into 
 consideration. Under 20 years of age general paresis is 
 very rare. From 40 — 60 it becomes rarer and rarer, and 
 after 60 it is hardly ever met with. In psychoses at this 
 age, which are similar to paretic insanity, careful differ- 
 entiation from senile insanity should be made. 
 
 Paretic insanity, as a rule, has a longer precursory 
 stage than other psychoses. This prodromal period 
 lasts from several months to a year and even longer. 
 Some French authors maintain that many patients pass 
 all their life in the precursory stage of paretic insanity. 
 But this assertion goes too far. 
 
 The most important feature of the precursory stage 
 consists in alteration of character. This symptom is not 
 indefinite, vague, or hardly noticeable, but is very striking. 
 The steadfast and upright man begins to be dissolute 
 and untrustworthy, the good father and faithful husband, 
 to neglect his family more and more. He may become 
 infatuated with a woman of low character and for her 
 sake abandon a happy home. A prominent psychiatrist 
 relates a case in which a patient in the precursory stage of 
 
248 PSYCHE 
 
 paretic insanity told his wife of his irresistible love for 
 one of his factory girls, insisting that she be taken into 
 the family. The symptom of alteration of character, 
 therefore, does not lack distinctness. It shows itself also 
 in a change of taste. The former favorite dishes are 
 refused by the patient, and he greatly relishes now food 
 which he used to dislike. 
 
 The alteration of character becomes still more con 
 spicuous through simultaneous impairment of memory. 
 The business man always attentive of, and retaining in 
 mind, the most insignificant trifles, becomes neglectful 
 and forgetful of the most important affairs. 
 
 The vitiation of character is further associated with 
 a weakening of intelligence. This is clearly shown by 
 the above example in which a husband with a sort of nai- 
 vete wants his wife to admit into her home a woman 
 with whom he has explicitly asserted to be in love. It is 
 quite characteristic of paretic insanity that weakness of 
 the understanding appears already in the initial stage of 
 the psychosis (p. 232). 
 
 In the precursory stage paretic patients render them- 
 selves guilty of manifold extravagances. Most of the 
 court proceedings in which paretics are involved refer 
 to excesses committed in this stage. 
 
 The precursory stage is marked by various somatic 
 disturbances. Sleep is greatly impaired. Frequently it 
 does not come before the morning. Instead, the patient 
 falls asleep at unusual times, for instance, while at the 
 dinner table. Now and then the patient is seized with 
 apoplectiform attacks marked by loss of consciousness. 
 These spells do not last long and leave no after-effects. 
 
 Motor disturbances of the precursory stage are slug- 
 gish reaction of the pupils, which may be narrow or un- 
 
SPECIAL PATHOLOGY 249 
 
 equal, and diminution or absence of the tendon reflexes. 
 Some patients show increased reflexes even in advanced 
 stages of the disease, but in those cases where the re- 
 flexes are absent at a later stage, they have been dimin- 
 ished or absent in the precursory stage. Many paretic 
 patients present also symptoms of tabes, such as rigidity 
 of the pupils, atactic gait, etc. There are also cases in 
 which for years only tabetic symptoms are present, and 
 then paresis suddenly supervenes. In such instances we 
 may speak of paresis .with a long precursory stage 
 marked by tabetic symptoms, or of tabes which has 
 been followed by paresis. Which view is correct must be 
 left undecided. 
 
 Sensory disturbances are common in the precursory 
 stage. Many a patient goes through all kinds of hydro- 
 therapeutic and other procedures to cure his "rhematism," 
 and at last he begins to show distinct symptoms of general 
 paresis. Impainnent of vision, for a long time attributed 
 to some cause or other, as to nicotine poisoning, is finally 
 recognized as a paretic symptom. 
 
 Under certain conditions the precursory stage is very 
 short or lacking altogether. When a syphilitic patient, 
 for instance, receives a severe trauma of the skull, he 
 may directly become a victim of general paresis, a pre- 
 cursory stage being hardly noticeable. But in the absence 
 of such a coarse injury to the brain a precursory stage 
 is not wanting. 
 
 The precursory stage is succeeded by an attack of 
 melancholia or of mania. After several such periods of 
 excitement follows the final stage of dementia. In these 
 periods, which may be separated by remissions, melan- 
 cholia and mania alternate or are irregularly repeated. 
 
250 PSYCHE 
 
 In some instances, however, the precursory stage passes 
 uninterruptedly into the dementia paralytica. 
 
 The melanchoHc excitement of paretic insanity re- 
 sembles ordinary melancholia, but is distinguished by the 
 absurdity of the delusions of self -depreciation (p. 55). 
 While in ordinary melancholia the patient would say he 
 is sinful, he is unworthy of nourishment, eternal damna- 
 tion will be his lot, the world will perish because of his 
 wickedness, etc., the paretic melancholic says he has 
 shrivelled to the size of a pigeon, he does not exist at all, 
 the world has already perished on account of his sins, etc. 
 These entirely nonsensical delusions are quite character- 
 istic of general paresis. 
 
 During the melancholic stage the somatic disturb- 
 ances make further progress. A defect of articulation 
 becomes manifest, the patient being unable to pronounce 
 certain words. In this respect faulty pronunciation of 
 difficult words is not of great importance. What is 
 more significant is that the patient mutilates every-day 
 words, but repeats them correctly when his attention is 
 called to the mistake. An uneducated person, many a 
 time, does not enunciate well complicated words, such as 
 artillery, electricity, etc. If, however, a patient corrupts 
 plain words when speaking in the usual manner, but pro- 
 nounces them without fault when he pays attention to 
 every word, a valuable symptom for the diagnosis general 
 paresis is obtained. Something similar holds good as 
 to writing. When the paretic patient is not more atten- 
 tive to his writing than ordinarily, it may be defective, 
 some strokes or whole syllables and words being omitted. 
 He is unable to write certain frequent words, as his own 
 name, at one stretch. But when he is very careful of his 
 writing, it may be fairly good. The slowness and care 
 
SPECIAL PATHOLOGY 251 
 
 the patient has to use in order to avoid mistakes and 
 omissions in writing, furnish an important paretic 
 symptom. 
 
 The melanchoHa is followed, sometimes preceded, 
 by a period of maniacal excitement. As a rule, it is in 
 such a stage that paretic patients are committed to the 
 insane asylum. The mania of paretic insanity differs 
 from ordinary mania by the absurdity of the delusions of 
 grandeur. They are not explained in any way, contain 
 a palpable nonsense, are full of contradictions, and in 
 great contrast with the patient's education (p. 55). Now 
 he maintains to be the emperor, now the pope or the 
 Lord himself. He possesses billions given to him by 
 the emperor of China. Questioned for what meritorious 
 feats the emperor has bestowed upon him so munificent 
 a gift, he answers he is himself the emperor of China. 
 Another paretic maniac would say his body consists of 
 precious stones, he has bones of diamonds, etc. When 
 a maniac asserts to possess billions, absurd delusion of 
 grandeur is not to be assumed at once, but he must be 
 asked how he obtained such wealth. A non-paretic 
 maniac will give some explanation. 
 
 Now and then the mania of paretic insanity is in- 
 terrupted by the so-called paralytic attacks. Usually oc- 
 curring in a maniacal stage, they have an apoplectiform 
 or epileptiform character. The patients recover from these 
 spells in a short time, a few days, and then the mania 
 continues. 
 
 The occurrence of remissions in the course of paretic 
 insanity is of special importance. The maniacal or mel- 
 ancholic excitement subsides, the patient becomes calm. 
 With the cessation of the morbid affective state the delu- 
 sions also disappear. The patient recognizes his delu- 
 
252 PSYCHE 
 
 sions as such and abandons them. He even admits that 
 he has been mentally ill, i. e., he gains the insight into the 
 disease (p. 129). But the rule that the rising conscious- 
 ness of having been mentally ill, constitutes a sign of 
 convalescence, does not hold good in the remissions of 
 paretic insanity. A remission in this psychosis is far 
 from convalescence. A hint that during such a stage the 
 mental disease has merely made a transitory standstill, is 
 furnished by the continuation of many motor disturb- 
 ances. The pupillary reaction is insufficient or absent, 
 the articulation and writing are defective, the gait is un- 
 steady. The patient becomes fatigued quickly, a short 
 walk makes him feel the need of sitting down and resting 
 his weary legs. These paretic symptoms are much less 
 noticeable in a remission than in the melancholic and 
 maniacal stages. For the patient has become quiet and 
 is, therefore, better able to direct his attention to these 
 functions. But these motor disturbances do not dis- 
 appear entirely during a remission. 
 
 The duration of the remissions varies. Rarely a re- 
 mission extends over a longer period than three years, 
 but remissions even of 20 years' duration do occur. In 
 a case in which the patient has died in a remission after 
 it had lasted for a very long time, we may speak of re- 
 covery from general paresis. But as a general rule, re- 
 covery from this psychosis is not to be counted upon. 
 
 The remission comes to an end through the out- 
 break of an acute exacerbation, which is usually caused 
 by the patient having overestimated his powers and taken 
 upon himself too difficult tasks. The exacerbation begins 
 all of a sudden in the form of maniacal or melancholic ex- 
 citement and makes the patient decline rapidly. A paretic 
 patient, therefore, must be dissuaded from resuming. 
 
SPECIAL PATHOLOGY 253 
 
 during a remission, his former hard occupation. For 
 the quieter a Hfe he leads, the longer the remission would 
 last. But even a patient who enjoys perfect rest is not 
 spared a recrudescence of the disease. 
 
 The recurrence of acute symptoms after a remission 
 exhausts the patient more than the first stage of excite- 
 ment. The paralytic attacks become more and more fre- 
 quent, and the patient usually passes soon into the final 
 stage of dementia. 
 
 The dementia of paretic insanity is not a stable con- 
 dition. The patient proceeds, at a rapid pace, on his jour- 
 ney towards the fatal end. He soon becomes unable to 
 walk, stand, sit upright, and swallow. Artificial feeding 
 has to be employed invariably. At times, even without 
 the intervention of paralytic attacks, (p. 251), he falls 
 into states of great weakness which last several days. 
 The feeding becomes more and more diflficult, the nutri- 
 tion insuf^cient, and through general exhaustion or some 
 intercurrent disease the patient's wretched life reaches 
 its termination. The autopsy reveals considerable patho- 
 logical changes in the brain cortex. 
 
 Prognosis and Differential Diagnosis. Because 
 of the prognosis the differential diagnosis of paretic insan- 
 ity is of great importance. When the physician has con- 
 vinced himself that a mental malady, as melancholia or 
 mania, is based on general paresis, he may put down the 
 prognosis as lethal, and declare to the patient's relatives 
 that cases of recovery from paretic insanity are so rare 
 that recovery is hardly to be taken into consideration. 
 
 Paretic insanity is distinguished by its peculiar pre- 
 cursory stage. A similar prodromal period does not oc- 
 cur in any other psychosis. Mania and melancholia in 
 the course of paresis are characterized by the absurdity 
 
254 PSYCHE 
 
 of the delusions of grandeur and of self -depreciation 
 respectively. Motor disturbances, such as rigidity of the 
 pupils, impairment of articulation and writing, unsteady 
 gait, etc., exclude all doubt of general paresis. 
 
 It does occur that an insane patient succumbs under 
 paretic symptoms, although in the beginning of the psy- 
 chosis paresis could not be demonstrated. In such a case 
 it is possible that we are dealing with a psychosis to 
 which paresis has supervened, or with paretic insanity 
 which did not commence in the typical manner. The 
 first assumption is more probable. For there is no known 
 reason why an insane person, as well as a sane one, should 
 not develop general paresis. 
 
 Therapy. — Antiluetic treatment has not proved to 
 be of beneficial effect on the course of paretic insanity. 
 In some instances it brings about a slight improvement, 
 but the latter is only transitory, and the morbid process 
 is afterwards accelerated in consequence of the weaken- 
 ing influence of the antiluetic procedures. 
 
 A good deal, however, can be accomplished to pro- 
 long the patient's life. If a paretic patient succumbs after a 
 comparatively short illness, the suspicion is justified thai 
 the treatment has been neglected, that he has not been 
 properly protected against the numerous dangers his 
 disease is attended with. Owing to deficiency of deglu- 
 tition, foreign material may be drawn in the deeper air 
 passages and pneumonia may result. The patient may 
 burn his oesophagus and stomach by swallowing too hot 
 food, become affected with cystitis through disturbance 
 of the function of the bladder, and contract phlegmons 
 from slight sores. All these dangers can be obviated by 
 careful circumspection. A paretic patient with deficiency 
 of deglutition must be assisted while eating or even arti- 
 
SPECIAL PATHOLOGY 255 
 
 ficially fed, especially when he has bronchitis, because 
 during an attack of coughing the danger of drawing par- 
 ticles of food into the lungs is very great. The evacuation 
 of bowels and bladder has to be regulated and watched. 
 The most insignificant lesion of the skin must not be dis- 
 regarded, but carefully treated. 
 
 Great difficulty of treatment is encountered during 
 long lasting paralytic attacks. One epileptiform or apo- 
 plectiform attack may follow the other, so that the patient 
 remains in an unconscious state for many days. It is 
 then necessary to introduce into the system a sufficient 
 quantity of fluid. This should not be done per os because 
 of the danger of aspiration into the lungs, but the fluid 
 should be given per rectum, very slowly and under slight 
 pressure, to prevent its being ejected. 
 
 Forensic Consideration. The paretic patient may 
 become involved in civil and criminal suits as early as the 
 precursory stage. Penal acts may be committed by the 
 patient in a stage of maniacal excitement and during a 
 remission. Civil suits at the precursory stage arise from 
 foolish extravagance of the patient which results to the 
 detriment of his family and of others. Criminal acts at 
 this period are such as perjury due to failing memory, 
 forgery, poisoning of the wife out of illicit love for an- 
 other woman, etc. In a maniacal stage paretic patients 
 commit acts of violence and render themselves guilty of 
 theft owing to the delusion that everything belongs to 
 them (p. 89), etc. The misdeeds perpetrated during a 
 remission are similar to those of the precursory stage, 
 especially when the patients resume their former occupa- 
 tions. 
 
 A difficult question for the physician to decide is 
 whether or not a paretic patient may be permitted to en- 
 
256 PSYCHE 
 
 joy, during a remission, the right to the control of his 
 estate. The physician will find it difficult to convince 
 the court that the patient ought to be adjudged incompe- 
 tent on the ground that he is only apparently sane, and 
 manifest insanity may set in again in full force at any 
 moment. For the court would hardly appreciate the sig- 
 nificance of a sluggish pupillary reaction and other slight 
 motor disturbances still noticeable in the patient, but 
 would rather consider such signs as trifles not furnishing 
 sufficient cause to declare the patient incompetent. 
 
 In some cases it is not requisite to divest paretic 
 patients, during remissions, of the right to the control 
 of their estates, in the same way as it is sometimes not 
 necessary to take away this right from secondarily insane 
 patients, for instance, when their fixed delusions have no 
 relation whatsoever with their financial afifairs. A pa- 
 retic patient in a remission may be allowed to manage 
 his revenue if he derives his livelihood from a monthly 
 pension. Leaving race deterioration out of the question, 
 we may even allow him to contract a marriage. If the 
 bride-to-be and the patient have been warned and made to 
 understand that a recurrence of the disease is to be ex- 
 pected, and nevertheless they do not desist from the mari- 
 tal union, the prospective bride, for instanc, insisting that 
 she wants to be to her beloved a faithful nurse in his 
 illness, the consent to their marriage cannot be justly 
 withheld. 
 
 If a paretic patient harbors a grudge against his rel- 
 atives for having caused his commitment to the insane 
 asylum or for any other reason, he should not be, during 
 a remission, in charge of his property. For he is apt to 
 disinherit them or sell everything he possesses and escape 
 with the proceeds. 
 
SPECIAL PATHOLOGY 257 
 
 Chapter XCV. 
 ALCOHOLIC INSANITY. 
 
 The consumption at one time of a large quantity of 
 alcohol produces a state of intoxication which, in all 
 exactness, represents an acute psychosis. The abuse of 
 alcohol extending over a long period, on the other hand, 
 brings about a condition which is designated as ^'chronic 
 alcoholism.'' The latter comprises a complex of symp- 
 toms in the sphere of the central nervous system and 
 some other organs. 
 
 The noxiousness of the various alcoholic beverages 
 is proportionate to the percentage of alcohol and the 
 amount of impurities, such as the fusel oils, which they 
 contain. Beer is, therefore, less injurious than wine, light 
 wine less than heavy wine, and brandy and whiskey more 
 injurious than wine. Li cold regions, combined with 
 much physical exertion and copious food, alcohol is com- 
 paratively well borne. 
 
 The manifestations of chronic alcoholism result from 
 the deterioration of many organs. Alcohol irritates the 
 upper part of the alimentary tract, causing chronic ca- 
 tarrh of the stomach — vomitus matutinus. It affects liver 
 and kidneys, producing cirrhosis of these organs — chronic 
 hepatitis and nephritis. The injurious influence of alco- 
 hol on the nervous system is shown by many nervous 
 symptoms, and these mainly constitute the chronic alco- 
 holism. 
 
 An early symptom of chronic alcoholism is the pecu- 
 liar depravity of character. The drinker neglects his 
 family, is unkind and rude to his wife, indifferent to his 
 business affairs, derelict in the duties of his vocation. 
 
258 PSYCHE 
 
 He has no feeling of honor, no self-respect. He is not 
 fastidious in the choice of his companions. An alcohoHc 
 of the best family and of high position will not be 
 ashamed to tope in company with individuals of the scum 
 of society. All these improprieties constitute the pecu- 
 liar alcoholic depravity of character. The deeper the 
 patient sinks, the more marked it becomes. 
 
 The habitual drinker is very irritable, sensitive, vio- 
 lent, and indifferent to his own life. In a fit of excite- 
 ment he is apt to assault anybody crossing his way, and 
 the subsequent annoyance at this impulsive act is suffi- 
 cient reason for him to commit suicide. 
 
 The alcoholic gets up in the morning with a certain 
 abhorrence of his existence. The thought of having to 
 perform his daily work renders him morose and weary 
 of life. This sour temper does not pass away before he 
 has taken recourse to his habitual stimulant, a glass of 
 wine or brandy. 
 
 It is difficult to establish the limit where chronic al- 
 coholism begins. One who consumes a great deal of 
 alcohol is not necessarily affected with this morbid condi- 
 tion. An individual with a strong constitution can stand 
 a great deal of alcohol, another one with a weak constitu- 
 tion manifests morbid symptoms at a much smaller con- 
 sumption of alcohol. The finest reagent to determine the 
 beginning of chronic alcoholism is inability to work. An 
 alcoholic who awakes in the morning feeling ill at ease, 
 morose, unable to work, and has first to take some wine 
 or brandy to get rid of this ill humor, is suffering from 
 chronic alcoholism. A drinker who cannot dispense with 
 alcohol without manifesting weakness, or, as the technical 
 term is, without symptoms of abstinence, is sick with 
 chronic alcoholism. A similar condition is met with in 
 
SPECIAL PATHOLOGY 259 
 
 chronic poisoning with morphine and nicotine. These 
 patients also cannot miss their habitual stimulants without 
 showing symptoms of weakness. The chief criterion for 
 the presence of chronic alcoholism is, therefore, the ap- 
 pearance of certain symptoms of abstinence when the use 
 of alcohol is interrupted. 
 
 An important symptom of chronic alcoholism is great 
 reduction of the will power. 
 
 All psychoses due to alcohol poisoning presuppose 
 chronic alcoholism, i, e., one who becomes mentally ill 
 through the abuse of alcohol has been affected with 
 chronic alcoholism for some time past. In all exactness, 
 the latter is also a mental disease as shown by the great 
 diminution of will power characteristic of the alcoholics. 
 They clearly see that they are steering towards the abyss 
 by continuing the abuse of alcohol, and yet they lack the 
 necessary strength of will to abandon it. Whether a psy- 
 chosis proper supervenes depends upon accidents and cir- 
 cumstances. The psychoses most common in alcoholics 
 are delirium tremens, hallucinatory insanity, epileptiform 
 insanity, primary insanity. 
 
 Delirium breaks out suddenly. When, for instance, 
 a drinker is arrested and put into prison where he 
 receives no alcohol, delirium tremens may set in over 
 night. Or when a drinker, seized with an acute disease, 
 is brought into the hospital where nobody even knows that 
 he is addicted to alcohol, delirium tremens may follow 
 quickly. The latter is a so-called delirium of abstinence, 
 i. e., it is caused by withholding the alcohol from the 
 habitual drinker. But there is also a delirium potatorum 
 caused by exaggeration of the usual consumption of alco- 
 hol. At some occasion the drinker may go far beyond 
 his ordinary limit, consuming at one time an excessive 
 
26o PSYCHE 
 
 amount of alcohol, which transgression may bring on an 
 attack of delirium. 
 
 Delirium tremens potatorum resembles the delirium 
 described before (Ch. "jy, p. 185). The delirious alco- 
 holic hallucinates vividly in several senses. His visual 
 hallucinations are quite characteristic. He sees many 
 small objects in lively motion or approaching towards him, 
 such as spiders, beetles, mice, rats, little men dancing, 
 etc. Delirium tremens is of shorter duration than other 
 deliria. In a comparatively short time, 8 to 10 days, the 
 patient recovers completely. \i however delirium tre- 
 mens be frequently repeated, the duration of the attacks 
 becomes longer and finally a state of permanent mental 
 enfeeblement may ensue. 
 
 More rapidly alcoholics advance towards mental de- 
 cay when they become affected with epilepsy. 
 
 Hallucinatory insanity is a frequent psychosis of the 
 alcoholics. Unlike in delirium, consciousness is not 
 disturbed in hallucinatory insanity. The patient is col- 
 lected, recognizes his surroundings, and is well aware of 
 what is going on around him. The hallucinations cause 
 delusions which are quite characteristic. The alcoholic 
 imagines that he is being deceived in his marital rights, 
 that rivals steal nightly into his home to carry on illicit 
 relations with his wife. Controlled by such delusions, 
 he walks at night about his house, weapon in hand, as- 
 saults anybody crossing his way, searches the corners and 
 closets of his room, stabs a knife into the bed, shoots out 
 of the window at passers-by, fancying them to be his 
 rivals in favor with his wife. These eccentricities con- 
 stitute the peculiar alcoholic delusions of jealousy. 
 
 Alcoholics sometimes become mentally ill under the 
 
SPECIAL PATHOLOGY 261 
 
 clinical picture of paranoia with delusions of furtherance 
 and grievance (Ch. 75, p. 176). 
 
 Differential Diagnosis. When it is known that 
 abuse of alcohol has preceded the psychosis to be deter- 
 mined and the characteristic alcoholic depravity of char- 
 acter can be established, the diagnosis alcoholic insanity 
 is assured. Drinkers may be confounded with those af- 
 fected with intolerance of alcohol. There are individuals 
 who can not stand alcohol, so that even a moderate con- 
 sumption of spirituous liquors produces in them symptoms 
 similar to those met with in excessive drinkers. 
 
 Forensic Consideration. Owing to great irritabil- 
 ity, alcoholics are apt to commit murder or other out- 
 rages at the slightest provocation. It is characteristic 
 that after the accomplishment of such violent acts they 
 attempt suicide. Delusions of jealousy may cause the 
 drinker to kill his wife or a presumptive rival. Neglect 
 of the duties of his office may also bring him in collision 
 with the Penal Code. 
 
 Therapy. The means at the disposal of the physi- 
 cian to cure chronic alcoholism are insufficient for the 
 reason that he is rarely in a position to have the drinker 
 deprived of his liberty for such length of time as would 
 be necessary to disaccustom him from the habitual use of 
 alcohol. Ordinarily an alcoholic can be legally committed 
 into an asylum only when it is possible to have him ad- 
 judged insane. But this is seldom the case. For, although 
 one day the drinker is irritable, morose, weary of life, and 
 loath to work, the next day he is discreet, cheerful, 
 amiable, and in a clever manner he knows how to conceal 
 or excuse his intemperance, so that the court does not 
 find sufficient cause for adjudging him insane. 
 
 To try to exert a moral influence upon the drinker, 
 
262 PSYCHE 
 
 to demonstrate to him that he will ruin himself by con- 
 tinuing the abuse of alcohol, would, from a theoretical 
 point of view, seem to be salutary. But practically all 
 endeavors to reform the alcoholic by moral persuasion 
 fail because of his great weakness of will power. When 
 he is committed into the asylum, he recognizes after a 
 comparatively short time that he has brought misfortune 
 upon himself and his family, and is all contrite in the most 
 desirable manner. By solemn promises he soon succeeds 
 to gain the confidence and favor of his relatives. The 
 latter take the patient away from the asylum, maintaining 
 that in his excellent condition of health and with such 
 sincere resolutions to renounce the alcohol, he can safely 
 be trusted and restored to liberty. But he has hardly 
 familiarized himself with the newly regained freedom 
 when the old trouble commences again. Nay, it happens 
 that the drinker beats his wife on the very day of his 
 dismissal from the asylum. Now, how is this possible? 
 Have all those solemn promises been false and hypocrit- 
 ical ? No, the sudden change in the patient's conduct may 
 be explained in another way. The promises and resolu- 
 tions have indeed been true and sincere. But after having 
 been removed from the wholesome restraint of the asy- 
 lum, the patient, in the first joy at the regained liberty, 
 begins to reason after this manner : ''One glass of wine 
 taken at your liberty will not harm you." When he has 
 once tasted alcohol, his good intentions begin to waver, 
 due to his weakness of will power. He drinks a second 
 glass and a third one, and so on, until he becomes intoxi- 
 cated. Now all the good resolutions are thrown over- 
 board. 
 
 It follows from the above that it is necessary to 
 detain the alcoholic for years in order to effect a perma- 
 
SPECIAL PATHOLOGY 263 
 
 nent cure. In some instances this is accomplished with 
 impecunious drinkers who have been put into prison for 
 some misdeed. But even in such cases it has been ob- 
 served that drinkers after dismissal from the prison have 
 again become addicted to alcohol. 
 
 Prognosis. The prognosis of alcoholic insanity is 
 generally very bad, as may be seen from the preceding re- 
 marks. But with regard to every single psychosis it is 
 comparatively favorable. Delirium passes off promptly, 
 so does hallucinatory insanity, even epileptic attacks cease 
 without leaving permanent mental enfeeblement. 
 
 Chapter XCVL 
 DELIRIUM ACUTUM. 
 
 Delirium acutum is a mental disorder of unknown 
 origin. It seems to be justified, however, to assume that 
 intoxication of some sort or other forms the exciting 
 cause. 
 
 The disease attacks persons in the prime of life and 
 is characterized by a very abrupt onset. Cases of deli- 
 rium acutum, therefore, are usually not observed in the 
 insane asylum, but in private or in the general hospital. 
 
 Delirium acutum presents the following clinical pic- 
 ture. Without any forebodings a young or middle-aged 
 person is suddenly seized with great excitement. He be- 
 gins to act in a frantic manner; he tears his clothes, de- 
 stroys everything within reach, and assaults everybody 
 coming near him. We might suppose that the patient 
 were suffering from an attack of mania. But a day or 
 two later it becomes noticeable that his consciousness is 
 
264 PSYCHE 
 
 considerably impaired, that he hallucinates strongly, that 
 his eyes lack the brilliant, fresh look of the maniac, and 
 the expression of his countenance betrays a serious condi- 
 tion. He takes no food, and his strength diminishes 
 rapidly, while in mania the vegetative functions proceed 
 rather favorably. The bodily temperature of the patient 
 is raised as high as 102° to 103°. At times he is quiet, 
 apathetic, almost stuporous. 
 
 Delirium acutum is usually lethal. The second week 
 of the disease is the most critical time. When the patient 
 has survived it there is some hope of recovery. 
 
 The following symptom is peculiar to delirium — 
 delirium acutum. The patient unexpectedly falls to the 
 ground, and this evidently by intention (p. 186). With- 
 out trying to ward off the fall by outstretching his hands, 
 he drops down in the most unfavorable manner, and then 
 he wallows and tries to force his head through carpets 
 or mattresses the floor may be covered with. All the 
 while he is under the influence of vivid hallucinations. 
 
 The condition of the patient in delirium acutum 
 frequently takes a sudden turn for the better. The 
 consciousness becomes entirely clear, the fever abates, and 
 the patient grows calm and takes nourishment willingly. 
 The relatives begin to attach little value to the physician's 
 assertion that notwithstanding the apparent improvement 
 the greatest danger is imminent. And indeed, a day or 
 two later the former grave symptoms reappear, and this 
 second attack leads to the lethal end. 
 
 At the autopsy great hypersemia of the brain is found 
 similar to the cerebral hypersemia after hanging. The 
 view has, therefore, been advanced that delirium acutum 
 is due to venous hypersemia of the brain caused by some 
 toxic agent. Acting upon this theory some have made 
 
SPECIAL PATHOLOGY 265 
 
 therapeutic use of ergotine and maintain to have had 
 good results with this treatment. The latter fact can not 
 be denied, but the conclusion drawn from it is doubtful. 
 For there are conditions which resemble delirium acutum 
 exactly and end in recovery without ergotine treatment. 
 The question of the beneficial effect upon delirium acutum 
 of ergotine would be decided by the following statistical 
 proceeding. Of all the cases commencing like delirium 
 acutum one should be treated expectatively, the next one 
 with ergotine; then again the 3rd, 5th, 7th, etc., expecta- 
 tively, and the 4th, 6th, 8th, etc., with ergotine. The 
 comparison of the two series will show which treatment 
 gives better results. In such an experiment the cases of 
 apparent delirium acutum will be quite evenly distributed 
 between the two modes of treatment. But if all cases are 
 treated with ergotine, the objection may be raised that 
 those terminating favorably have not been cases of de- 
 lirium acutum, but merely resembled it. 
 
 Chapter XCVII. 
 TRAUMATIC INSANITY. 
 
 Traumatic insanity is traceable to an injury, espe- 
 cially of the skull. The coma immediately following the 
 shock excluded, the mental disorders of traumatic insanity 
 appear in three distinct types. 
 
 One type consists in violent hallucinations. The 
 patient having recovered from the disturbance of con- 
 sciousness subsequent to the trauma, begins to hallucinate 
 strongly in several senses, and this although no bodily 
 lesion of any importance can be established. This ex- 
 citative state persists for weeks, so that serious symptoms 
 
266 PSYCHE 
 
 of exhaustion arise, rendering artificial feeding necessary. 
 Nevertheless the prognosis is favorable if there are no 
 signs of pareses and paralyses. After a few weeks con- 
 valescence commences and is soon followed by complete 
 recovery. 
 
 Of longer duration is that form of traumatic insanity 
 which presents the clinical picture of paranoia. Some 
 time after the trauma disturbances of the emotional 
 sphere begin to oppress the patient and become productive 
 of delusions of grievance and furtherance (Ch. 75, p. 
 176). This type of traumatic insanity is also of favor- 
 able prognosis even in cases where the paranoia lasts for 
 a year and longer. 
 
 A third form of mental disorder based on trauma 
 manifests itself by great excitability of the central nervous 
 system associated with intolerance of alcohol. The quan- 
 tity of spirituous liquors which up to the time of the 
 trauma the patient could consume without the slightest ill 
 effect, exerts now an injurious influence on his nervous 
 system. It puts him into a state of extraordinary excite- 
 ment, almost of frenzy. The condition of the patient is 
 such that he may be taken for an alcoholic in delirium 
 tremens. This diagnosis would not be a matter of in- 
 difference to the patient. For the mental disorders based 
 on chronic alcoholism are ultimately to be ascribed to 
 bad habits and wrong actions, while traumatic insanity 
 with intolerance of alcohol is not due to any fault of the 
 patient's. 
 
 The degree of irritability of the central nervous sys- 
 tem is commensurate with the exaggeration of the tendon 
 reflexes. It is, therefore, possible to judge of the in- 
 creased excitability of the patient by the condition of his 
 reflexes. 
 
SPECIAL PATHOLOGY 267 
 
 Therapy. Injuries productive of traumatic insan- 
 ity usually cause a concussion of the brain in toto whereby 
 its excitability becomes increased and its power of resist- 
 ance diminished. For this reason surgical interference is, 
 as a rule, of no avail. In some instances, however, it has 
 a good effect. The skull is, therefore, to be examined for 
 depressions or fractures, and the lesions found are to be 
 treated according to surgical principles. If no injury of 
 the skull can be established, the treatment is only symp- 
 tomatic. The patient must be guarded against excite- 
 ment and strong sense stimuli, and the use of alcohol 
 and tobacco is to be strictly forbidden. 
 
 Chapter XCVIII. 
 INSANITY IN ORGANIC BRAIN DISEASES. 
 
 Mental disorders are frequently due to organic dis- 
 eases of the brain. 
 
 Huntington's chorea is a psychosis consisting in a 
 slowly progressing mental deterioration with pronounced 
 dementia as the final stage. Besides choreic movements 
 of limbs and body, the patients present various psycho- 
 pathic symptoms, such as impairment of memory and 
 judgment, apathy, irritability, groundless outbursts of 
 anger. At times depression or mania is present. The 
 disease runs a course of 10 to 30 years. In the terminal 
 dementia the patients are physically so weak that they 
 have to be kept in bed. The autopsy reveals consider- 
 able pathological changes in the meninges and cerebral 
 cortex. 
 
 Multiple Sclerosis. Multiple sclerosis is usually 
 associated with psychopathic symptoms. The affective 
 
268 PSYCHE 
 
 state is that of depression in early stages of the disease. 
 Later sHght euphoria prevails. Occasionally uncontroll- 
 able emotional outbursts occur. The patients laugh or 
 weep without provocation. Apathy is often present. 
 Memory and judgment are defective. The insight into 
 the morbidity of the mental condition (p. 129) is pre- 
 served for a long time. 
 
 Apoplexy. Cerebral hemorrhages frequently lead 
 to an impairment of the mental faculties. In many in- 
 stances the patients become apathetic. Their lack of 
 emotional control is seen in outbursts of laughing or 
 weeping without apparent cause. The power of memory 
 and judgment is diminished. The insight into the dis- 
 eased mental condition is wanting in some cases, but well 
 retained in others. 
 
 Brain Tumor. Mental defects are met with in 
 tumors of the brain, especially in large ones and those of 
 the frontal lobes. The patients become indifferent, for- 
 getful, unable to endure any mental exertion. Memory is 
 weakened. Attacks of somnolence occur frequently. 
 Sometimes there is childish cheerfulness with inclination 
 to joking. 
 
 Cerebral Syphilis. The mental disorders due to 
 syphilis of the brain are divided into two types, simple 
 syphilitic dementia and syphilitic pseudoparesis. The dif- 
 ferentiation of these two types, however, is sometimes 
 impossible. 
 
 In simple syphilitic dementia there is an impairment 
 of memory and judgment. Apoplectiform and epilepti- 
 form attacks are frequent. The affective state is often 
 exalted. The patients are subject to emotional outbursts 
 and show marked intolerance of alcohol. The insight 
 into the disease is wanting. 
 
SPECIAL PATHOLOGY 269 
 
 Syphilitic pseudoparesis usually begins with a state 
 of depression. The patients become indifferent and for- 
 getful. At times they are very irritable and violent. 
 Hallucinations are frequent, especially in the sense of 
 hearing. Delusions of persecution are present, but they 
 are unstable. Later there is -exaltation associated with 
 delusions of grandeur. The final stage is marked by a 
 more or less pronounced dementia, some patients being 
 capable of useful occupation, others unfit for any work. 
 Some physical symptoms contribute to render syphilitic 
 insanity still more similar to paretic insanity. The pupil- 
 lary reaction is somewhat impaired, and the pupils may 
 be unequal in size. Difference of innervation of sym- 
 metrical parts and tremor in the muscles of the face, 
 tongue, and extremities, are noticeable. 
 
 It is very difficult to differentiate syphilitic insanity 
 from paretic insanity. In the former the memory is not 
 impaired to such an extent as in the latter. The char- 
 acteristic defective articulation of general paresis is want- 
 ing in syphilitic insanity. 
 
 Antiluetic treatment is of little avail in syphilitic in- 
 sanity, yet it may be tried. 
 
 Chapter XCIX. > 
 
 SENILE INSANITY. 
 
 In senility the vigor of mind shows a gradual pro- 
 gressive decline. Through the consuming effect of time 
 the old memory images have either faded away or have 
 become so faint that they can hardly be reproduced. The 
 present sensations fail to leave impressions, do not 
 
270 PSYCHE 
 
 ''cling, " in the deteriorated cerebral elements. The asso- 
 ciative paths are worn out by age, and association is 
 hereby rendered difficult. The power of reasoning, de- 
 pending upon memory and association, is therefore im- 
 paired. This mental enfeeblement of old age, called 
 dotage, is to be considered physiological, since it is 
 founded on the natural deterioration of the brain through 
 senescence. There is, however, in advanced age an im- 
 pairment of the mental faculties which is due to patho- 
 logical factors and may therefore be designated as senile 
 insanity. 
 
 Senile insanity is founded on an exaggeration of the 
 brain's senescence in the general senile alteration of all 
 organs. It appears under the clinical pictures of melan- 
 cholia and mania followed by dementia. Some patients 
 show all these three forms of mental disorder, one after 
 the other, in other patients the melancholia or the mania 
 is missing. The succession of the clinical pictures of 
 senile insanity is, therefore, as follows: (i) Melan- 
 cholia — Dementia; (2) Mania — Dementia; (3) Melan- 
 cholia — Mania — Dementia. In some instances senile in- 
 sanity has the periodic character, melancholic or maniacal 
 excitement alternating with intervals of well-being. 
 
 The melancholia of senile insanity has some charac- 
 teristic traits. The patients are troubled with groundless 
 cares of sustenance. Although possessed of wealth, they 
 complain about dire poverty and assert that they have to 
 deny themselves everything in order to save for their 
 children. We would be inclined to regard such patients 
 as old misers. But when we see that their sleep is dis- 
 turbed, their nutritive state greatly reduced, and their 
 strength gradually waning, we will recognize that it is not 
 niggardliness which causes the patients' worries about 
 
SPECIAL PATHOLOGY 271 
 
 their own subsistence and that of their dear ones. These 
 cares about sustenance may drive the patients to suicide. 
 Many a case of suicide at an advanced age is to be attrib- 
 uted to senile melancholia. 
 
 Senile mania also shows some peculiarities. The 
 senile maniac feels young again. He boasts that in spite 
 of his 70 years he can accomplish as much as a man of 
 30. He dresses like a young man, after the newest 
 fashion, carries a walking cane in his hand and a cigar in 
 his mouth, and in this attire he flaunts about the streets. 
 Confidentially he betrays to a companion that his virile 
 potency is excellent. This last point must be borne in 
 mind for the reason that senile maniacs frequently come 
 into conflict with the Penal Code in consequence of sexual 
 overexcitement. Driven by their morbid sexual desires 
 they importune not only other people's children, but even 
 render themselves guilty of illicit relations with their own 
 grandchildren. People sometimes speak of an old liber- 
 tine who had to go to the penitentiary for rape. But the 
 physician cognizant of the fact that sexual excitement 
 belongs to the symptoms of senile mania, will, in a given 
 case, investigate the matter somewhat closer. He will 
 try to find out whether the defendant has manifested other 
 indications of mental disease, and having established this, 
 will plead for his acquittal on the ground of insanity. 
 
 A serious feature of senile insanity is the unexpected 
 occurrence of fatal apoplexies. This will not appear ex- 
 traordinary when we consider that the senescence of the 
 brain, which is the chief etiological factor of senile in- 
 sanity, is founded on atheromatosis of the cerebral blood 
 vessels, and this pathologic-anatomic alteration is also the 
 cause of cerebral hemorrhages. The relatives of the 
 patient must be warned that fatal termination through 
 
272 PSYCHE 
 
 apoplexy occurs unexpectedly in senile insanity. If their 
 attention has not been called in time to this eventuality, 
 they are distrustful when a misfortune happens suddenly, 
 and suspect that their patient has been ill treated or 
 neglected, and it may become necessary to prove by 
 autopsy the cause of his precipitate death. 
 
 Prognosis. During the melancholic or maniacal ex- 
 citement death may result from exhaustion. The refusal 
 of food in senile melancholia is much more fraught with 
 danger than in insanity of young patients. Sudden apo- 
 plexies may speedily end the patients' lives. When how- 
 ever the acute stages of senile insanity have passed off 
 without fatal termination, the patients enter into the more 
 permanent stage of dementia. Their condition is then 
 less changeable, their conduct less dangerous than for- 
 merly, and they are, therefore, fit for private care. 
 
ERRATA 
 
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INDEX 
 
 Aboulia, jy^ 222. 
 Abstinence, 123, 175, 258, 259. 
 Acoustic nerve, 7. 
 Activity, 234. 
 Adolescence, 153, 224. 
 Affective sphere, 36, 160, 181, 
 
 197, 199, 204, 224. 
 Affective state, 14, 17-18; in 
 
 hallucinatory insanity, 170; in 
 
 paranoia, 176. 
 Affective tones, 13 ; physiologic- 
 anatomic explanation of, 14; 
 
 a. t. in compulsory ideas, 72; 
 
 in idiocy, 197, 201, 204, 208. 
 Age and psychoses, 153. 
 Agoraphobia, 39, 71. 
 Agricultural system of insane 
 
 asylums, 139. 
 Akinetic stereotypy, 80. 
 Alcohol, 7, 108, 116, 194, 233, 
 
 257, 267. 
 Alcoholic beverages, 116, 257. 
 Alcoholic insanity, 257. 
 Alcoholism, chronic, 117, 257. 
 Alienation, 103. 
 Alternating insanity, 236. 
 Amnesia, 60, 64, 65, 246. 
 Anaesthesia of the skin, 98. 
 Anaesthesia, general, to subdue 
 
 an unmanageable patient, 136. 
 Analysis, 21. 
 Angry mood, in hallucinatory 
 
 insanity, 170; in mania, 163, 
 
 166. 
 Antiluetic treatment, value of a. 
 
 t. in paretic insanity, 254; in 
 
 syphilitic insanity, 269. 
 Anxiety, a cause of insanity, 
 
 113; emotional attacks of 
 
 anxiety, 33, 34, 154, 158. 
 
 Aphasia, 65. 
 
 Apathy, 189, 225, 267, 268. 
 
 Apoplectiform attacks, 93, 227- 
 
 248, 251, 255. 
 Apoplexy, 268, 271. 
 Apperception, 21. 
 Appetite, 156, 167, 170, 182. 
 Argyle-Robertson pupil, 97. 
 Arsenic poisoning, 118. 
 Arson, 199, 202. 
 Articulation, faulty, 97, 127, 
 
 250. 
 Assimilation, 156, 158, 167, 170, 
 
 182. 
 Association, 8, 19-20; facility 
 
 of, 73; difficulty of, 74; fibres 
 
 of association, 8, 15, 23. 
 Asymetry of the skull, iii, 197, 
 
 199, 216. 
 Astraphobia, 71. 
 Asylum, 137. 
 Atheromatosis, 271. 
 Attention, 21 ; monopolizing of 
 
 the a. by hallucinations, 52. 
 Atropine, 94, 118. 
 Auditory hallucinations, 46; in 
 
 paranoia, 177. 
 Aura of the epileptic attack, 
 
 243- 
 Automatism, 7, 79, 90, 229; of 
 command, 82, 91 ; of imita- 
 tion, 82, 226. 
 
 Barrenness of the affective 
 
 sphere, 36, 160, 189, 224. 
 Baths, 158, 188. 
 Beer, 117, 257. 
 Bladder, disorders of, 97, 159, 
 
 254- 
 Blind, mentally, 11. 
 
274 
 
 INDEX 
 
 Blindness, visual hallucinations 
 in, 45. 
 
 Blood, its importance for the 
 brain, 5, 17; loss of b., a cause 
 of insanity, 156, 160, 192. 
 
 Brandy, 117, 257. 
 
 Cachexia strumipriva, 216. 
 
 Canities, 96, 156. 
 
 Care of sustenance, a cause of 
 insanity, 113. 
 
 Carotid arteries, compression 
 of, 5, ^y. 
 
 Catalepsy, 82, 230. 
 
 Catatonia, 230. 
 
 Cerebro-spinal fluid, 16, 196. 
 
 Changeling, 215. 
 
 Character, alteration of charac- 
 ter in paretic insanity, 247; 
 alcoholic depravity of charac- 
 ter, 257. 
 
 Child, overburdening of the c, 
 a cause of insanity, 114. 
 
 Chloral hydrate, 118, 144, 188. 
 
 Cholera, 115. 
 
 Chorea, Huntington's, 267. 
 
 Circular insanity, 127, 163, 233, 
 236. 
 
 Circulation, sluggish blood cir- 
 culation, 156, 191. 
 
 Civilization, 104. 
 
 Claustrophobia, 71. 
 
 Climacterium, 153, 240. 
 
 Closed institutions, 139. 
 
 Clubfoot, 112. 
 
 Cocaine, 94, 113, 118. 
 
 Colobomata, 112. 
 
 Comparisons, in the activity of 
 the understanding, 21. 
 
 Composite feeling, 14. 
 
 Compulsion, mechanical, in the 
 treatment of the insane, 140. 
 
 Compulsory actions, 86. 
 
 Compulsory ideas, 39, 68, 72. 
 
 Concussion of the brain, 267. 
 
 Confounding of persons, 68, 
 185. 
 
 Confusion, 52, 173, 184, 185. 
 
 Consciousness, 27; c. and mem- 
 ory, 65; c. and sleep, 90; dis- 
 turbance of, 65, 90, 93, 160, 
 185, 187, 227, 230. 
 
 Constriction of the nasal root, 
 216. 
 
 Contact, fear of, 70. 
 
 Contrary sexual feeling, 212. 
 
 Convalescence, 72, 96, 128. 
 
 Convolution, frontal, 203. 
 
 Coprolalia, 39. 
 
 Coprophagia, 38, 39. 
 
 Corpus callosum, 203. 
 
 Corti, organ of, 7. 
 
 Cretinism, 196, 214. 
 
 Crime, family history of, 108; 
 punishment for, 76 ; source of, 
 56, 175. 
 
 Critique, "want of c," 74. 
 
 Crying, instinct of, 26. 
 
 Cryptorchismus, 208. 
 
 Cyanosis, 156, 228, 243. 
 
 Cystitis, 254. 
 
 Deaf, psychically, 11. 
 
 Death, a termination of psy- 
 choses, 131. 
 
 Death of a near relative, a 
 cause of insanity, 113. 
 
 Deduction, 21. 
 
 Decubitus, 98. 
 
 Deglutition, impairment of, 145, 
 
 254. 
 
 Dejection, 31, 234. 
 
 Delirium, 185 ; differentiated 
 from melancholia, 157; from 
 mania and hallucinatory in- 
 sanity, 187; deliria of absti- 
 nence, 123, 259 ; in drug pois- 
 oning, 118; in infectious dis- 
 eases, 115; d. marked by 
 numerous hallucinations, 51 ; 
 by abrupt onset and rapid 
 course, 123, 125. 
 
 Delirium acutum, 123, 263. 
 
 Delirium tremens, 123, 259. 
 
INDEX 
 
 275 
 
 Delusions, definition and source 
 of, 34, 36, 52, 53-54; classifi- 
 cation and diagnostic value 
 of> 55-56; d. in alcoholic in- 
 sanity, 260; d. productive of 
 morbid impulses, 89; — of in- 
 crease of energy, 85 ; — of per- 
 verse acts, 39; — of refusal of 
 food, 96, 144; effect of hyp- 
 notism on d., 147. 
 
 Dementia, i) primary curable, 
 192; differentiated from mel- 
 ancholia, 156; from secondary 
 dementia, 193; from stupor, 
 160; 2) secondary, 189; form- 
 ing final stage of psychoses, 
 130, 169; differentiated from 
 stupor, 160; nutritive distur- 
 bances in d., 96, 191 ; reduc- 
 tion of energy in d., 84 ; para- 
 lytic d., 249; senile d., 270; 
 simple syphilitic d., 268. 
 
 Dementia praecox, 56, 153, 224; 
 — paranoides, 230. 
 
 Depression, cardinal symptom 
 of melancholia, 154-156, 159, 
 163, 233; criteria for morbid 
 d., 31 ; its influence on the 
 psychical functions, 33; treat- 
 ment, 141, 147; d. in hallu- 
 cinatory insanity, 170; in de- 
 mentia praecox, 229. 
 
 Depressive excitement, 237. 
 
 Derailment of the will, 81. 
 
 Dermography, 228. 
 
 Destructiveness, 140, 143, 230. 
 
 Devilry, 48, 50, 51, 179, 215. 
 
 Digestion, 156, 158, 167, 170, 
 182. 
 
 Diphtheritic paralyses, 115. 
 
 Disorientation, 94, 185. 
 
 Disputatiousness, 209. 
 
 Doggerel, 226. 
 
 Dotage, 270. 
 
 Double consciousness, 92. 
 
 Doubting habit, 70. 
 
 Doute, folie du doute, 70. 
 
 Drunkenness, 108. 
 
 Duration of the psychoses, 125. 
 
 Dwarfishness, 196, 216. 
 
 Ear, fautly development of, iii. 
 
 Eccentricity, 108, 224. 
 
 Echolalia, 82, 226. 
 
 Echopraxia, 82, 2.26. 
 
 Ecstasy, 159. 
 
 Educability, "want of e.," 205. 
 
 Emotion, 14; emotions in idiocy, 
 n, 197, 200. 
 
 Egotism, 220. 
 
 Energy, 83; decrease of, 36, 84, 
 154, 156; increase of, 36, 83, 
 85, 156, 157, 166, 176, 182. 
 
 Equilibrium of the body, 97. 
 
 Epilepsy, 120, 242-246; in al- 
 coholics, 260; in idocy, 197; 
 family history of, 108; per- 
 verse feelings in e., 38 ; deliria 
 in e., 186; short psychoses in 
 e., 126; states of clouded con- 
 sciousness in e., 66, 92; epil- 
 epsy differentiated from mel- 
 ancholia, 157. 
 
 Epileptic attack, 243. 
 
 Epileptic insanity, 242, 259, 260. 
 
 Epileptiform attacks, 93, 227, 
 251, 255. 
 
 Ergotine, 265. 
 
 Ethical conceptions in idiocy, 
 197, 204. 
 
 Euphoria, 268. 
 
 Exaltation, cardinal symptom of 
 mania, 162, 163, 234; criteria 
 for morbid e., 34-35; its in- 
 fluence on the psychical func- 
 tions, 35-36 ; treatment, 141 ; 
 e. in hallucinatory insanity, 
 170. 
 
 Exciting causes of insanity, 103. 
 
 Exercises, 143, 158, 161. 
 
 Exertion, a cause of insanity, 
 113. 
 
 Falling down, intentional, 186, 
 264. 
 
276 
 
 INDEX 
 
 Family history of insanity, 107, 
 108. 
 
 Feeble-mindedness, epileptic, 
 242; secondary, 133, 169, 189. 
 
 Feeding, artificial, 144, 157, 161, 
 181, 254, 255. 
 
 Feeling, 13; physiologic-ana- 
 tomic explanation of, 14. 
 
 Fever, 115, 157, 185, 264. 
 
 Fickleness, 112, 201. 
 
 Fire, predilection for, 199. 
 
 Fixed delusions, 59, 130, 182. 
 
 Flexibilitas cerea, 82, 160. 
 
 Flight of ideas, 36, 42, 74, 86, 
 164, 234. 
 
 Forensic consideration, in alco- 
 holic insanity, 261 ; — compul- 
 sory ideas, 87 ; — dementia 
 praecox, 229; in determining 
 the beginning of a psychosis, 
 125; in epilepsy, 66, 244, 246; 
 — imbecility, 63, 202, 203; — 
 mania transitoria, 126; — mor- 
 bid mood, 33; — paranoia, 180; 
 — paretic insanity, 248, 255- 
 256; in psychoses caused by 
 imprisonment, 1 14 ; — querul- 
 ous insanity, 209-210; — secon- 
 dary insanity, 184; — senile in- 
 sanity, 271 ; — sexual perversi- 
 ty, 212, 214; in want of free- 
 dom of the will, 25, 56, '^6] 
 see also crime, malingery, 
 Penal Code. 
 
 Forgery, 255. 
 
 Freedom of the will, 25, 56, y6. 
 
 Fright, a cause of insanity, 113. 
 
 Furtherance, delusions of, 55, 
 57, 176, 179. 
 
 Fusel oil, 117. 
 
 Gait, defective, 97. 
 
 Gangrene, 98, 135, 188. 
 
 Gaps of memory, in epilepsy, 
 
 66, 93; in hysteria, 6y. 
 "Gedankenarme Manie," 237. 
 
 "Gedankenreiche Melancholia," 
 
 239- 
 
 General paresis, 246-256; ab- 
 surd delusions in, 56; age, 
 153, 247; anaesthesia, 99; 
 Argyle-Robertson pupil, 97 ; 
 apoplectiform and epilepti- 
 form attacks, 93, 227; early 
 intellectual enfeeblement, 232 ; 
 frequency in civilized lands, 
 105; handwriting, 166; in- 
 crease of energy, 84; impair- 
 ment of memory, 64, 65; of 
 understanding, 75 ; klepto- 
 mania in, 89, 168; long pre- 
 cursory stage, 123; prognosis, 
 131, 134, 253; remissions, 
 127, 251 ; differentiation from 
 dementia praecox, 232; from 
 recurrent insanity, 241 ; — sy- 
 philitic insanity, 269. 
 
 Genius, 108. 
 
 Giftedness, family history of, 
 108. 
 
 Goitre, 196, 202, 216, 228. 
 
 Grandeur, delusions of, 55-57, 
 142, 165, 166, 179. 
 
 Grievance, delusions of, 55, 56, 
 156, 173, 176, 179. 
 
 Grimacing, 237. 
 
 "Griibelsucht," 70. 
 
 Hair, graying of, 96, 156. 
 
 Hallucinations, 42-46; sequelae 
 and symptoms of, 51 ; audi- 
 tory h., 45, 46; gustatory, ol- 
 factory, and tactile h., 50; 
 visual h., 45, 49. 
 
 Hallucinatory idea, image, 11, 
 44. 
 
 Hallucinatory insanity, 170, 260, 
 265; differentiated from me- 
 lancholia, 157; from delirium, 
 187. 
 
 Handwriting, 127, 166. 
 
 Hanging, disturbance of mem- 
 ory after, 6y; hyperaemia of 
 
INDEX 
 
 ^17 
 
 the brain after, 264; suicide 
 through, 145. 
 
 Heart, disturbance of the activ- 
 ity of, 99. 
 
 Hebephrenia, 228. 
 
 "Heitere Verstimmung," 234. 
 
 Hemiplegia in idiocy, 196. 
 
 Hepatitis, 257. 
 
 Heredity, 107. 
 
 Hereditary insanity, 168, 218. 
 
 Hereditary predisposition to in- 
 sanity, 107, 108, no, 112, 218. 
 
 Hernia, congenital, 112. 
 
 Homicidal mania, 88, 230. 
 
 Homicide, marked by brutality, 
 244, 245. 
 
 Homosexuality, 40. 
 
 Honor, violation of h., a cause 
 of insanity, 113. 
 
 Hydrocephalus, 196. 
 
 Hyperaemia of the brain, 264. 
 
 Hypermetropia, excessive, 112. 
 
 Hypermnesia, 60, 63, 74, 200. 
 
 Hypersuggestibility, 82, 226. 
 
 Hypnotics, 117, 144. 
 
 Hypnotism, 91 ; a therapeutic 
 measure, 147. 
 
 Hypoboulia, 78. 
 
 Hypochondria, 96, 222, 228, 229. 
 
 Hypospadia, 112. 
 
 Hysteria, anaesthesia in, 99; 
 disturbance of consciousness, 
 93; family history of, 107- 
 108; psychoses of short dura- 
 tion in, 126. 
 
 Hysterical insanity, 219. 
 
 Idea, 9; course or train of 
 ideas, 13; dominant idea, 159, 
 160. 
 
 Ideational process, 13, 41 ; in- 
 fluence of the affective state 
 upon, 18-20; acceleration of, 
 35, 36, 42, 165 ; retardation of, 
 33, 41, 155; in hallucinatory 
 insanity, 170; in stupor, 159. 
 
 Ideational sphere, impairment 
 of, 130; in paranoia, 176. 
 
 Idiocy, 195; barrenness of the 
 affective sphere in, 36; de- 
 crease and increase of energy 
 in, 85, 86; increased capacity 
 of memory in, 62, 63 ; — of un- 
 derstanding, 74; irritable af- 
 fective state in, 38; perverse 
 feelings in, 38; inferior idi- 
 ocy, 197; superior idiocy, 199. 
 
 Idiomuscular swelling, 228. 
 
 Illusion, 42-44, 53, 60, 154, 155, 
 
 243- 
 
 Imagination, 21. 
 
 Imbecility, 196, 199. 
 
 Imitation, instinct of, 27. 
 
 Immobility of thought, 234. 
 
 Imperative action, 86. 
 
 Imperative idea, see compul- 
 sory. 
 
 Imperative impulse, 86. 
 
 Impotence, virile, 40. 
 
 Impression, 7-8; failure of sen- 
 sations to leave impressions, 
 64, 65, 269 ; destruction of im- 
 pressions, 65. 
 
 Impulse, natural, see instinct. 
 
 "Impulse action," 26. 
 
 Imprisonment, a cause of in- 
 sanity, 114, 117. 
 
 Inactivity, 234. 
 
 Indeterminism, 25. 
 
 Induction, 21. 
 
 Infectious diseases, 115, 116, 
 156, 160, 162, 186. 
 
 Infinitives, mode of speech of 
 idiots, 198. 
 
 Initial symptoms of psychoses, 
 mistaken for their cause, 124. 
 
 Insanity, definition, 103, 
 
 Insight into the disease, 128- 
 129, 223, 268. 
 
 Insolation, 162. 
 
 Insomnia, 6, 118, 144. 
 
 Instinct, 26. 
 
278 
 
 INDEX 
 
 Institutional treatment of the 
 sane, common reluctance to, 
 132. 
 
 Interference, 81. 
 
 Intermarriage, 106. 
 
 Interval, free interval of period- 
 ic insanity, 126, 129. 
 
 Intolerance of alcohol, 261, 266, 
 268. 
 
 Intoxication, 154, 157, 175; al- 
 cohol intoxication, 117, 257. 
 
 Intuition, 12. 
 
 Iodoform poisoning, 118. 
 
 Irascibility, 200. 
 
 Irritability of the brain, 5. 
 
 Isolation, symptoms of isola- 
 tion, 166. 
 
 Jaw, deformity of, iii. 
 Jealousy, alcoholic delusions of, 
 
 260. 
 Jews, frequency of insanity 
 
 among J., 106-107. 
 Judgment, 21. 
 
 Kinetic stereotypy, 80. 
 Kleptomania, 88, 168. 
 
 Lactation, 219, 240, 
 
 Lead poisoning, 118. 
 
 Legal matters, see forensic con- 
 sideration. 
 
 Liquor cerebro-spinalis, 16. 
 
 Litigiousness, 209. 
 
 Love, rejected 1., a cause of in- 
 sanity, 113. 
 
 Lucid interval, 240. 
 
 Lues, 115, 268. 
 
 Macrocephalia, 196. 
 
 Malingery, 33, 39, 53, 87, 126, 
 143, 167, 246. 
 
 Mannerism, 80, 226, 239. 
 
 Mania, 162-169; in paretic in- 
 sanity, 249; — recurrent insan- 
 ity, 235-236, 241 ; — senile in- 
 sanity, 271 ; differentiated 
 
 from delirium, 187, 263; — 
 hallucinatory insanity, 173 ; 
 paranoia, 180. 
 
 Manic, maniacal, definition, 162. 
 
 Maniacal affective state, 35. 
 
 Maniacal excitement, delusions 
 of grandeur in, 55; improve- 
 ment of memory, 61 ; of un- 
 derstanding, 73; increase of 
 energy in, 83; increased vo- 
 litional activity, 78. 
 
 Manic-depressive insanity, 163, 
 
 233- 
 
 Massage, 143, 158, 161. 
 
 Melancholia, 154-158; m. agita- 
 ta, 155, 238; in paretic in- 
 sanity, 249-250 ; — recurrent in- 
 sanity, 235-236, 241 ; in senile 
 insanity, 270; differentiated 
 from hallucinatory insanity, 
 174; — paranoia, 180; dimin- 
 ished frequency of volitional 
 manifestations in m., 78; di- 
 minution of energy, 84; re- 
 fusal of food, 143. 
 
 Melancholic affective state, 33. 
 
 Melancholic excitement, 221. 
 
 Medullated nerve fibres, 8. 
 
 Memory, 11; disturbance of m., 
 60, ^y ; diminished capacity of 
 m., 64-67; abnormally in- 
 creased capacity of m., 61-63; 
 m. in dementia praecox, 225; 
 — hallucinatory insanity, 170; 
 — idiocy, 199, 200 ; — mania, 
 42, 61, 163; melancholia, 154; 
 — Huntington's chorea, 267 ; 
 — multiple sclerosis, 268. 
 
 Memory image, 9, 20. 
 
 Meningitis, 196. 
 
 Menstruation, 240. 
 
 Mental overexertion, a cause of 
 insanity, 113. 
 
 Mercury poisoning, 118. 
 
 Metabolism of the brain, 5. 
 
 Microcephalia, 196, 202. 
 
INDEX 
 
 279 
 
 Mind, I. 
 
 Mixed states in manic-depres- 
 sive insanity, 163, 237. 
 
 Mobility of thought, 234. 
 
 Modernized delusions^ 179. 
 
 Monomania, 89, 167. 
 
 Mood, 14; treatment of morbid 
 m., 141. 
 
 Moral idiocy, moral insanity, 
 196, 204. 
 
 Morphinism, 118, 123. 
 
 Motor disturbances in the in- 
 sane, 97. 
 
 Motor image, impression, 8. 
 
 Motor sensation, 7. 
 
 Murder, 156, 180. 
 
 Muscular irritability, increase 
 of, 228. 
 
 Muscular power, abuse of, 84. 
 
 Mutism, 83, 229. 
 
 Mysophobia, 71. 
 
 Myxoedema, 216. 
 
 Nagging mania, 237. 
 
 Nails, nutritive disturbance of, 
 
 96. 
 
 Nanism, 216. 
 
 Negativism, 82, 226, 229. 
 
 Nephritis, 257. 
 
 Neurasthenia, 222; family his- 
 tory of, 107, 108. 
 
 Neurology, i. 
 
 Neuropathology, i. 
 
 New-born, movements of, 22. 
 
 Nicotine poisoning, 249. 
 
 Non-freedom of the will, 25, 56, 
 76, 212. 
 
 "Norgelnde Manie," 237. 
 
 Nutritive state of the brain, 16, 
 
 Nymphomania, 88, 168. 
 
 Oblique posture of the body, 97. 
 Obliquity of the skull, ill, 196. 
 Occipital lobe, 7. 
 Oedema, 156, 158, 161, 228. 
 
 Oesophagus, foreign body in, 
 
 146; lesion of, 146. 
 Onset of the osychoses, 123. 
 Optic nerve, 7. 
 Opium, 118. 
 
 Orientation, 28, 160, 185, 238. 
 Originary insanity, 211. 
 
 Pachymeningitis haemorrhagi- 
 ca, 95. 
 
 Paraldehyde, 145. 
 
 Paralogia, 83, 227. 
 
 Paralytic attacks, 251. 
 
 Paranoia, 176-181 ; in alcoholic 
 insanity, 261 ; — hysterical in- 
 sanity, 221 ; traumatic insan- 
 ity, 266; delusions in p., 56, 
 58, 74; p. differentiated from 
 hallucinatory insanity, 173; — 
 melancholia, 156; — originary 
 insanity, 211; increase of en- 
 ergy in p., 85; periodic p., 
 128; want of critique in p., 
 
 74- 
 
 Paresis, a disturbance of the 
 bodily equilibrium, 97; pa- 
 reses in idiots, 196. 
 
 Paretic insanity, 246, 269; see 
 general paresis. 
 
 Pavilion system of insane asyl- 
 ums, 139. 
 
 Pederasty, 40, 212-213. 
 
 Pellagra, 118. 
 
 Penal Code, conflict of insane 
 patients with, 68, 180, 184, 
 202, 212, 221, 245, 261, 271 ; 
 see forensic consideration. 
 
 Perceiving, modes of, 12. 
 
 Perception, 11. 
 
 Periodic insanity, 126, 128, 163, 
 168, 233; periodic mania, 236, 
 270; — melancholia, 236, 270; 
 — paranoia, 128, 181. 
 
 Perjury, 255. 
 
 Persecution, delusions of, 155, 
 179, 229. 
 
 Perspiration, 186, 228. 
 
28o 
 
 INDEX 
 
 Perturbations, physiological, 218, 
 219, 239, 240. 
 
 Perverse feeling, 38. 
 
 Perverse sexuality, 40, 212. 
 
 Phantasy, 12. 
 
 Phlegmon, 146, 188, 254. 
 
 Phobias, 70, 71, 222. 
 
 Phonomania, 88, 168. 
 
 Phrenasthenia, 222^ 232, 242. 
 
 Physiological latitude, 45. 
 
 Pneumonia, aspiration pn., 254. 
 
 Poison, fear of, 51, 144. 
 
 Poisons in the etiology of in- 
 sanity, 116. 
 
 Porencephalia, 197. 
 
 Postepileptic insanity, 243, 244. 
 
 Precordial anxiety, 34. 
 
 Predisposing causes of insanity, 
 103. 
 
 Predisposition to insanity, 63, 
 107-110. 
 
 Preepileptic insanity, 243, 244. 
 
 Pregnancy, 39, 219, 240. 
 
 Prognathism, iii, 216. 
 
 Pseudoparesis syphilitica, 268- 
 269. 
 
 Psychasthenia, 73, 'jy, 222. 
 
 Psyche, i. 
 
 Psychic, psychical, definition, i. 
 
 Psychic equivalents of the epil- 
 eptic attacks, dd, 92, 120, 126, 
 157, 186, 242-245. 
 
 Psychical influences in the eti- 
 ology of insanity, 113. 
 
 Psychiatry, i. 
 
 Psychology, i. 
 
 Psychomotor inhibition, 238. 
 
 Psychosis, 103; classification of 
 the psychoses, 151. 
 
 Puberty, 153, 218, 224. 
 
 Puerperium, 219, 240. 
 
 Punishment, in non-freedom of 
 the will, 'jd', of embecile chil- 
 dren, 201. 
 
 Pupillary reaction, 97, 127, 248, 
 256, 269. 
 
 Pyelonephritis, 98. 
 Pyromania, 88, 168, 199. 
 
 Querulous insanity, 209. 
 
 Rabies, fear of, 71. 
 
 Ragamuffins suffering from de- 
 mentia praecox, 229. 
 
 Raptus melancholicus, 221. 
 
 "Rat's ear," iii. 
 
 Reason, 21. 
 
 Reasoning, 21. 
 
 Recurrent insanity, 126, 128, 
 ^53' 163, 219, 233; recurrent 
 mania, 236; — melancholia, 
 236; — paranoia, 128, 181. 
 
 Reflex movements, 7, 22, 78, 
 
 159, 160. 
 Reflex arc, 22. 
 
 Refusal of food, in delirium, 
 1 86 ; — dementia, 96 ; — halluci- 
 natory insanity, 170, 172, 173; 
 — hypochondria, 96 ; — hysteri- 
 cal insanity, 220; melancho- 
 lia, 96, 143, 157, 272; — para- 
 noia, 85, 96, 143; — stupor, 96, 
 143; danger of r. o. f. in 
 senile insanity, 272; treat- 
 ment, 138, 143-144, 147. 
 
 Regurgitation of food, 146. 
 
 Relations in the activity of the 
 understanding, 21. 
 
 Religion, in the etiology of in- 
 sanity, 106. 
 
 Religious insanity, 178; r. para- 
 noia, 179, 180. 
 
 Remissions, 127, 251. 
 
 Responsibility of the family 
 physician, 132-133. 
 
 Resistance in the nervous ele- 
 ments, 19-20. 
 
 Rest cure, 158. 
 
 Retina, 7. 
 
 Retiring disposition, 112. 
 
 Regidity of the muscles, 159, 
 
 160, 230. 
 Rigor mortis, 146. 
 
INDEX 
 
 281 
 
 Scarlatina, 115. 
 Sclererosis, multiple, 167. 
 Secale cornutum, 118. 
 Secondary insanity, 59, 181. 
 Secretiveness, 112. 
 "Seelenblind," 11. 
 "Seelentaub," 11. 
 Self-consciousness, 27, 28, 94, 
 
 198. 
 Self-depreciation, delusions of, 
 
 55-58, 155-158. 
 Self-mutilation, 85, 180. 
 Self-preservation, instinct of, 
 
 27, 88. 
 Semi-consciousness, 90, 92, 244. 
 Senescence, 270. 
 Senile insanity, 169, 247, 269. 
 Sensation, 7; pure sensation, 
 
 II. 
 "Sensation cells," 8. 
 "Sensation fibres," 8. 
 Sense feeling, 13. 
 Sense impressions, 7. 
 Senses, 6, 7. 
 
 Sensibility, disturbance of, 98. 
 Sensory image, 7. 
 Sensory elements, 8. 
 Serodiagnostic investigation, 1 16. 
 Sexual excitement, 168, 220, 
 
 271. 
 Sexual perversity, 40, 212. 
 Shock, a cause of insanity, 113. 
 Sitophobia, 96. 
 Skin, anaesthesia of, 98, 99; 
 
 cyanosis of, 156; fatty and 
 
 oedematous degeneration of, 
 
 216; impaired nutrition, 96; 
 
 lesions of, 147, 255. 
 Skull, deformity of, iii, 196, 
 
 199, 216. 
 Slavering, 159. 
 Sleep, 6, 90, 95, 156, 161, 176, 
 
 182, 223. 
 Sleeplessness, see insomnia. 
 Smiling, instinct of, 26. 
 "Snouting cramp," 80. 
 
 Somatic disturbances in the in- 
 sane, 95. 
 Somnambulism, 90. 
 Somnolence, 95, 268. 
 Speech, faculty of s. in idiots, 
 
 195, 197, 199. 
 
 Spirituous liquors, 116. 
 
 Stereotypy, 79, 80, 226, 229. 
 
 Stigmata of hereditary predis- 
 position to insanity, no. 
 
 Stimulants, for facilitating the 
 association, 73; habitual, 113, 
 117, 259. 
 
 Strain, mental, a cause of in- 
 sanity, 113. 
 
 Straight-jacket, 135. 
 
 Strangulation, 145. 
 
 Stupor, 37, 78, 84, 96, 159, 162, 
 228-231, 264. 
 
 Sucking, instinct of, 26. 
 
 Suggestion, 146. 
 
 Suicide, dy, 96, 105, 133, 138, 
 145, 156, 157, 258, 261, 271; 
 family history of, 108. 
 
 Sulfonal, 145. 
 
 Surprise, joyful, a cause of in- 
 sanity, 113. 
 
 Synchondrosis, 216. 
 
 Synthesis, 21. 
 
 Syphilis, 115, 268. 
 
 Syphilitic dementia, simple, 268. 
 
 Systematized delusions, 58, 174, 
 178, 211. 
 
 Tabes, 97, 115, 249. 
 
 "Tardy" pulse curve, 99. 
 
 Temperature, decrease of, 156; 
 increase, 115, 185, 264. 
 
 Temporal lobe, 7. 
 
 Tension in the nervous ele- 
 ments, 19, 20. 
 
 Termination of the psychoses, 
 128. 
 
 Theft, 88, 255. 
 
 Thyroid gland, 202, 216, 217. 
 
 Tics, 79, 225. 
 
 Tobacco, 73, 113, 233, 267. 
 
282 
 
 INDEX 
 
 Tongue, faulty innervation of, 
 
 97. 
 Toxic insanity, 153, 257. 
 Toxines, 115, 116, 186. 
 Tractability of the maniacs, 86, 
 
 142, 167, 169. 
 Transport of insane patients to 
 
 the asylum, 134. 
 Trauma, 118, 175. 
 Traumatic epilepsy, 93. 
 Traumatic insanity, 265. 
 Traumatic psychoses, 119, 153. 
 Traumatism, 103. 
 "Traurige Verstimmung," 233. 
 Tremor, 228, 269. 
 Trophoneurotic disturbances, 98. 
 Tumor of the brain, 268. 
 Typhoid Fever, 103, 115. 
 
 Understanding, 20, 73, 276. 
 
 Vagabonds suffering from de- 
 mentia praecox, 229. 
 
 Vasomotor center, 16. 
 
 Vasomotor disturbances, 228. 
 
 Vegetative processes, in hallu- 
 cinatory insanity, 170; — ma- 
 nia, 163, 167; — melancholia, 
 156 ; — paranoia, 1 76 ; — sec- 
 
 ondary dementia, 191 ; stupor, 
 160. 
 
 Venous system of the brain, 15. 
 
 Verbigeration, 80, 226. 
 
 Vertebral arteries, 5. 
 
 Vertebral canal, 16. 
 
 Visual hallucinations, 49 ; — of 
 the alcoholics, 260. 
 
 Volitional action, simple, 26. 
 
 Volitional manifestations, de- 
 crease of the frequency of, 
 77-79, 155, 159; increase of, 
 yy, 78, 166; V. m. in halluci- 
 natory insanity, 170. 
 
 Vomitus matutinus, 257. 
 
 "Vorbeireden," 83, 227. 
 
 "Wechselbalg," 215. 
 
 Weight, bodily w. in psychoses, 
 
 96, 128. 
 Whiskey, 117, 257. 
 Will, 22-25; morbid activity of, 
 
 y^j; treatment of m. a. of, 142. 
 Wine, 73, 117, 257. 
 Word-salad, 227. 
 Worry, a cause of insanity, 113. 
 Writing, defective, 127. 
 
 "Zornige Manie," 237. 
 "Zwangsideen," 68. 
 
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