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 MENTAL DISORDERS 
 
 Briefly Described and Classified 
 
 WITH 
 
 A Few Remarks on Treatment 
 and Prevention 
 
 By CHARLES B. THOMPSON, M. D. 
 
 Medical Director of the Mental Hygiene Societj' of Maryland 
 Assistant Dispensary Psychiatrist The Phipps Psychiatric Clinic, The Johns Hopkins Hospital 
 
 Baltimore 
 
 WARWICK ^' YORK, Inc. 
 
 1920 
 

 -V- ' •-•• v*: ; ••' .•,'./ file -^v, 
 
 £J 
 
 -t.. -V 
 
 CONTENTS 
 
 THE TWO TYPES OF MENTAL DISORDERS 
 
 A. Those associated with physical or chemical injury to brain tissue 5 
 
 B. Those which seem to exist only on psychological bases 5 
 
 A. MENTAL DISORDERS WITH DEFINITE INJURY TO BRAIN 
 
 TISSUE 
 
 L PHYSICAL INJURY— ORGANIC BRAIN DISEASE— Loss of Tissue. 5 
 
 1. General Paresis .^ 5 
 
 2. Traumatic Disorders <r' 
 
 a. Delirium immediately following the accident 8 
 
 b. Various degrees of loss of memory r- 8 
 
 c. Conditions due to localized injury S 
 
 d. Post-traumatic constitution T 8 
 
 e. Terminal deterioration S 
 
 3. Senile Psychosis : 8 
 
 4. Arteriosclerotic Ps3-chosis 9 
 
 5. Localized Injury _ 9 
 
 6. Diffuse Nervous Diseases 
 
 a. Tuberculosis of the brain r 9 
 
 b. Tuberculous Meningitis . .' 9 
 
 c. Multiple Sclerosis 10 
 
 d. Huntington's Chorea 10 
 
 7. Brain Tumor 10 
 
 8. Brain Syphilis 10 
 
 9. Brain Abscess. .• 10 
 
 TO. "Organic Brain Disease" 10 
 
 11. Idiocy and Feeble-Mindedness (congenital or due to injury at birth) 10 
 
 12. Constitutional Inferiority 11 
 
 J [. CHEMICAL OR TOXIC INJURY— Injury by Poisoning 1 1 
 
 1. Alcoholic Psychoses 1 1 
 
 a. Pathological Intoxication 11 
 
 b. Delirium Tremens i- 
 
 c. Acute Hallucinosis ~. . . . . i-i 
 
 d. Alcoholic Constitution 12 
 
 e. Alcoholic Paranoid States i- 
 
 f . Korsakoff's Ps3'chosis 13 
 
 2. Drug Psychoses , I3 
 
 a. Drug Habits 13 
 
 b. Accidental Poisoning by Drugs 14 
 
 c. Trade Poisoning by Drugs 14 
 
 d. Illuminating Gas Poisoning 14 
 
 e. Food Poisoning , 14 
 
 2 
 
CONTEXTS CONTINUED 3 
 
 3. Toxic-Infective-Exhaustive Reaction Type 15 
 
 a. Febrile (infection) 15 
 
 Delirium 15 
 
 Incidental Depressions in the course of certain diseases 15 
 
 b. Tnxic-Exhaustive 16 
 
 Uremic, Diabetic, or Eclamptic Disorders 16 
 
 Thyroid Disturbances 16 
 
 c. Exhaustive — Extreme Lack of Sleep 16 
 
 COMBINED A. AXD B. DISORDERS 
 
 1. Psychoses of Pregnancy 16 
 
 Treatment 17 
 
 Post Partum Psychoses 18 
 
 2. Epilepsy , 18 
 
 B. DISORDERS EXPLICABLE IX PSYCHOLOCxICAL TERMS 
 
 How Emotion Guides Behavior 20 
 
 I. THE MARKED MENTAL DISORDERS. 22 
 
 1. Elation-Depression Oscillation (.Manic-Depressive Psychosis) 22 
 
 2. Depressions Other than of Manic-Depressive Group 25 
 
 a. That caused by disease (more properh^ under Toxic) 25 
 
 b. Depression with hallucinations. . . .^ 26 
 
 c. Depression with paranoid trend 26 
 
 d. Agitaied Depression 26 
 
 3. Atypical Excitements 26 
 
 ■ 4. Paranoiia 2~ 
 
 5. Dementia Precox . 28 
 
 a. Simple Type 29 
 
 b. Hebephrenic 3^ 
 
 c. Catatonic 3 ' 
 
 d. Paranoid 3- 
 
 Discussion of Development of Dementia Precox 34 
 
 II. THE NEUROSES OR "NERVOUSNESS", OF APPARENTLY WELL 
 
 PEOPLE 4' 
 
 1. Neurasthenia A- 
 
 2. Psychasthenia 4'-' 
 
 3. Hysteria 4- 
 
 4. Anxiety Neurosis 4- 
 
 Discussion of Causes of Neuroses 43 
 
 PRINCIPLES OF TREATMENT OF MENTAL DISORDERS 44 
 
 PRINCIPLES OF PREVENTION OF MENTAL DISORDERS 47 
 
 List of Four References 48 
 
 5032i»ti 
 
INTRODUCTION 
 
 This syllabus has been written in response to the growing desire for 
 knowledge in Psychiatry. The method pursued has been, first, to 
 describe the common disorders ; second, to deduce therefrom a few 
 essential principles as to causation and treatment. 
 
 It may perhaps be noted that the subject of child psychology, except 
 in the discussion of Dementia Precox, lias not been touched upon. 
 Child psychology cannot be considered a thing apart from adult psy- 
 chology. The two are continuous and identical, and we have but one. 
 Human Psychology. The earlier phases of this are best studied through 
 the Freudian literature and psycho-analysis. These show that the^ 
 neuroses and many of the psychoses are distortions of this infantile 
 mind coming into contact with the conditions and facts of everyday life. 
 
 I would suggest that this pamphlet be used as far as possible in con- 
 junction with actual observation of cases, and in consultation with a 
 trained psychiatrist. 
 
 All classifications, and especially this one, must be regarded as being- 
 more or less tentative, but while not final they enable us to utilize the 
 definite facts which are already known.- If this outline establishes a 
 few landmarks and furthers a little the interest in its field it will have 
 served its purpose. 
 
 Baltimore, Md. C. li. 'J\ 
 
 April, 1920. 
 
MENTAL DISORDERS 
 
 ^Icntal disorders fall into two general classes : 
 
 A. Mental disoidcrs in 'chicli the re is definite injury to brain tissue. 
 Since the mind is dependent on the hrain, there are mental changes as 
 a consequence of the injury to the hrain suhstance. 
 
 B. Mental disorders zehieJi seem to be explicable entirely on a 
 psychological basis. These have heen called emotional disturhances, 
 "functional diseases," or emotional maladjustments. 
 
 The details of Class A. -are given first. Xo mental disorder can 
 be assumed to exist upon purely a psychological basis until the possi- 
 bilities of physical illness have been eliminated by all the tests known 
 to medicine. 
 
 A. :\IEXTAL DISORDERS WITH DEFINITE INJURY TO 
 
 BRAIN TISSUE 
 
 These are of two kinds according as the injury is 
 
 ( I ) pJiysieal. with absolute loss of brain tissue, forming the Organic 
 Psychoses. The injury may have been caused by infection, hemorrhage, 
 accident, arteriosclerosis, or some similar agent. These mental changes 
 are permanent. 
 
 (2) chemical from poisons — called toxines — floating in the blood, 
 hence acting on the brain tissue, and causing brain changes and imental 
 symptoms, forming the Toxic Psychoses. The toxine may be an actual 
 poison which has been taken into the body, such as an overdose of 
 alcohol or opium, or it may arise from infection in the body, or be 
 generated by a diseased organ within the body. These Psychoses may 
 be permanent or only transitor}'. 
 
 I. Psychoses ^^'lTH Loss of Braix Tissue. 
 
 These have certain general characteristics, Memory Defect — there 
 are absolute "holes in the memorv" as if certain events or vears had 
 never happened ; great A'ariation in Judgment — this is good one time, 
 poor another ; a very obvious Loss of Ability to Grasp Situations ; 
 sometimes attacks resembling epilepsy in appearance. 
 
 I. GENERAL PARESIS. 
 
 This is characterized by a deterioration of the mind and character 
 due to a progressive damage to brain tissue, the cause being syphilis of 
 the brain. 
 
 A formerly staid member of the community suddenly or gradually 
 becomes careless in his appearance, in his behavior, and in his business 
 habits. 
 
 There are gross lapses of memory, the most critical things are 
 
6 MliNTAt DISORDERS 
 
 jovially forgotten. Important business engagements are made and 
 not kept, large deals are let go hang in the imost haphazard fashion 
 or other large deals are undertaken without judgment. His judgment 
 is so impaired that he has delusions of grandeur, (grandiose ideas or 
 Megalomania), everything is described by him in heroic style — he 
 runs several hundred miles in a half hour; his friends and relatives 
 are the monarchs of the various countries throughout the world ; he is 
 building a bridge to Europe ; possesses millions and millions of dol- 
 lars, etc. At the same time he shows tremendous gaps of memory, 
 particularly of past events, leaving out periods of lo or 15 years in 
 giving a story of his life, and being unable to make any but the simplest 
 calculations. 
 
 And the patient seems utterly oblivious to these as to all his other 
 mistakes, in fact, he is highly pleased with his performance. His 
 mood is generally that of euphoria or exaggerated self-complacency, 
 the patient seeming to have no insight as to the pitifully small extent 
 of his real capacities. 
 
 Further, there is a characteristic slurring speech with repetition of 
 syllables, sometimes of words, such as "Third Artililerary Brigrgrade" 
 or "Hypotapamus, hypotapamus, hypotapamus." There is often a 
 great tremor of hands, and tremulous gait. Spinal fluid taken by 
 lumbar puncture shows characteristic luetic changes (positive Wasser- 
 mann, positive gold chloride test, high cell count). Blood Wassermann 
 is often positive. In the later stages of the disease the patient deteri- 
 orates to such an extent that only the vegetative functions remain. He 
 can but eat and sleep. There may be convulsions. Though as a rule 
 the patient is unaware of his real condition, sometimes his insight is 
 very clear and he is most distressed at watching his own mental dis- 
 integration. . • 
 
 The most dangerous point of the disease is that with this loss of 
 memory and inefficiency, there are combined very exaggerated ideas of 
 his own prowess and ability, so that the many complications which may 
 arise when this disease comes upon a man in a responsible position, 
 engaged in many important business dealings, may be tremendous. 
 It is highly important to detect, if possible, an incipient case. 
 
 The onset is not always as sudden and as remarkable as given above ; 
 it may, on the contrary, be quite gradual and insidious. ]\Iany incipient 
 cases of General Paresis have gone undiagnosed for a time, or have 
 been considered to be mild excitement or depression. Diagnosis is im- 
 portant because of the prognosis which in General Paresis is always 
 very gloomy, at least until further advances in the methods of medica- 
 tion have been worked out. 
 
 As early symptoms there imay be merely change in disposition — a 
 usually tidy person may become careless as to his general appearance ; 
 
MKNTAL DISORDERS 7 
 
 occasional odd behavior — grossly inappropriate remarks may suddenly 
 make their appearance ; lapses of memory, or perhaps a sudden and 
 transitory loss of consciousness may take place. The patient may 
 become somewhat restless, or somewhat elated. A more careful test of 
 memory, especially of retention, would show defects. There may 
 often be a beginning speech defect in test phrases ; there may be tremor 
 of facial muscles or of the hands, or a beginning tremulous, uncertain 
 gait. Lumbar puncture here is conclusive, the characteristics being a 
 high cell count, strongly positive globulin test, positive Wassermann 
 and gold chloride test. 
 
 GENERAL PARESIS 
 
 The patient was a young woman of 26 who had been arrested for shop-lifting, 
 having jusi helped herself right and left wherever her fancy pleased. Moreover, 
 she had placed orders in various other stores for five hundred shirts, dozens of 
 pairs of stockings, etc. Her husband was a small Jewish tailor. 
 
 The woman appeared to be a young Jewish woman of a1)out 28, who was quite 
 euphoiic and had a very lackadaisical manner. She talked very freely about 
 herself, husband, etc. Said that she is an actress at the Hippodrome in the 
 afternoons and evenings, also a waitress at Childs' in the mornings, and makes, 
 with her husband, -a great deal of money. Speaks of having paid $500 for a 
 brooch, also $500 for a necklace, $300 for an automobile, etc., etc. Says that 
 she has six children, and is supposed to have none. Says that her husband, 
 who is a tailor, will make the doctor a suit of clothes for a Christmas present. 
 She is also going to buy him a motorcycle with a sidecar, and he can take her 
 out in it. She pulls out a blue silk handkerchief which she says her "gentle- 
 man friend," an Italian fellow, gave her. Tells the doctor she will give it to 
 him and throws it on his desk. She talks of a dancing academy which she and 
 her husband are going to establish on Greenmount .Vve., and says that she 
 bets the doctor will enjoy coming there. She spoke of having nine nieces, 
 all of whom are going to marry well — doctors, engineers, etc. — and they are 
 going to have nine weddings, all at the Emerson Hotel. 
 
 Her memory for dates is quite poor. Says she was married at 14. has been 
 married 15 years, and is now 26. Does not see her error. Says her oldest child 
 is 14, was born four years after marriage, there having been two still-births 
 before that time. 
 
 ADVANCED CASE OF GENERAL PARESIS 
 
 The patient was a man of 48 who had been unable to work for a year. When 
 first seen he was standing in his store diilly trying to fasten his cuff, but being 
 prevented by his great tremor. He had the typical greasy yellow complexion, 
 and talked with scanning speech. 
 
 His first remark was, "I ain't sick." He had little memory for past events ; 
 did not know the name of the street in front of his store, and finally gave the 
 name of one in another part of town. He gave his age as 42. 
 
 He frequently would wander out into the town, and be unable to find his 
 way back. 
 
 Throughout the interview he kept repeating, ''I ain't sick. I got hundred 
 dollar Liberty Bond. I ain't sick. I got hundred dollar Liberty Bond." 
 
8 - -MENT^\L DISORDERS 
 
 2. IR AUMATIC DIS ORDERS. (TRAUMA — INJURY), THOSK CAUSED V,Y 
 
 ACCIDENTAL IX^URY TO BRAIN. 
 
 These do not follow even' accident by any means. As a rule thev 
 take place only when the accident has been so severe that the patient 
 remains unconscious for hours or even days. Any one of the foilownig" 
 may come separately, or it may appear combined with one of the otner 
 types : 
 
 a-. Dcliriiini iiuuiediatcly follozving the accident, i. e., loss of knowl- 
 edge of the time and place — the patient has no idea as to the date or 
 the situation, whether hospital or home, he may think it a ship, fort, 
 wqrkshop, etc. He may possibly have hallucinations. 
 
 The previous presence of alcoholism or senility may add coloring 
 or duration to the picture. 
 
 h. Various degrees of loss of Jiiemory combined with apparently 
 hysterical condition. 
 
 c. Conditions due to local i.ced iiijury to one part of the brain, such 
 as aphasia, with injury to speech mechanism, the patient may lose 
 the ability to write or read ; or asymbolia, wherein he loses all power 
 of communication even by signs, etc. These may occur at once or they 
 
 ■may appear later as residual conditions. 
 
 d. Posi-trauniatic constitution, easily affected by alcohol, grippe, 
 fatigue, etc., with headaches or tendency to sudden and unwarranted 
 outbursts of temper. Possibly with paranoid development (delusions 
 of persecution or grandeur), or depression. 
 
 e. Conditions of deterioration coming considerably later from pro- 
 gressive changes in injured tissue, characterized by loss of memory, and 
 loss of efficiency and of mental activity. 
 
 The patient before his accident was a telegraph hneman. He is aged 27. 
 
 He left school at the age of 13, in the 4th grade. 
 
 He had always been a hard worker. 
 
 On July 3, 1913, he fell 25 feet to the ground, landing on his left side. He 
 was unconscious for 12 days. He remembers nothing until August, 1913. 
 
 Now he does not remember having climbed the pole, and remembers nothing 
 concerning two to three days before the accident, (retrograde amnesia). He 
 forgets events which occurred during the two weeks after he regained con- 
 sciousness, (anterograde anmesia). 
 
 Since the accident there has been, according to the account of his relatives. 
 a marked change in his efficiency and disposition. As seen in the hospital he 
 cannot remember what he did during the just previous hour (going to town in a 
 carriage) ; he has difficulty in recognizing people; difficulty in recognizing voices 
 of friends over the telephone: his memory is impaired; he gets tired easily; he 
 suffers from loss of confidence in himself; he has a violent temper and is easily 
 irritated and restless ; he considers his symptoms chiefly due to hospital life. 
 Many references to end it all by suicide. Finally he left the hospital dissatisfied 
 and irritated. 
 
 3. SENILE PSYCHOSIS. 
 This occurs, of course, generally in the aged, though there aie 
 some cases of premature senility as in cases of arteriosclerosis. The 
 symptoms are forgetfulness, particularly of very recent events, con 
 
MENTAL DISORDERS 9 
 
 trasted at times with a surprisingly clear memory of childhood events ; 
 a poor grasp of situations and indecision. Also the patient is particu- 
 larly apt to get confused when called upon to transmit a message ; or 
 when he is obliged to act quickly and decisively, as, for instance, in 
 crossing the street. If given abundance of time, however, he may 
 get along satisfactorily. The patient is liable to sudden attack's of agi- 
 tation or restlessness, especially at night when he may be overcome by a 
 desire to get up and go somewhere, not knowing where or why, with 
 afterwards entire forgetfulness of these attacks. Delirium may 
 occur. 
 
 The patient is a laborer of 59. Whereas he had not worked for one year 
 before the examination, he expressed himself as having been regularly in the 
 employ of Swift & Co., and having worked the day before, or not longer than 
 a week before. That he had injured his foot then in an accident (this had been 
 months before). He stated that he received $15 a week, but to account for his 
 not having any money in his pockets, he accused his daughter, at whose house 
 he lived, of being in the habit of picking his pockets while he was asleep. He got 
 rather excited over this. 
 
 He was mistaken as to the date, said it was early in January when it was 
 February 3rd, but was oriented for place and person. He was liable to extreme 
 outbursts of temper, getting extremely angry with his daughter over very small 
 incidents. At night he would often get up and wander about the house : 
 sometimes, he would turn on the gas without lighting" it. apparently not 
 realizing what he was doing, and go back to bed again leaving the gas turned on. 
 
 4. ARTERIOSCLEROTIC PSYCHOSIS. 
 
 As a rule, this otuiffsin men or women of advanced age, but it may 
 occur in middle-aged or young people as a result of arteriosclerosis, 
 and may cause premature senility. The symptoms, which may appear 
 singly or in any sort of combination are a tendency to become easily 
 irritated or moved to tears ; loss of memory and a general dulling of 
 acuteness ; headache and ringing in the ears ; signs of localized 
 injury, such as aphasia; attacks of confusion with loss of sense of the 
 time and place. At times there is a placid, contented or rather happy 
 frame of mind. As an occasional, though striking, symptom, the 
 patient will fall asleep at all other odd moments, often in the middle 
 of a conversation. There are other signs of arteriosclerosis, tingling or 
 numbness in the hands or feet. 
 
 5. VARIOUS STATES OF MIND DEPENDING ON LOCAL INJURIES 
 
 WITH Aphasia, Asymbolia, etc. 
 
 6. DIFFUSE NERVOUS DISEASES. 
 
 a. Tuberculosis of brain. 
 This is marked by dullness, defect of judgment and memory, dis- 
 orientation, stupor. Often a demonstrable tuberculous lesion else- 
 where in the body as a primary focus from which the brain injury has 
 developed. 
 
 b. Tuberculous uieniiigitis. 
 The signs are excitement followed by lethargy with all the signs 
 of meningitis, characteristic spinal fluid. 
 
• 10 ~ MENTAL DISORDERS 
 
 c. Multiple Sclerosis. 
 Symptoms are apathy, combined with deterioration. 
 
 The patient, a man of 38, had been a laborer, but had finally been prevented 
 from working by his progressive paralysis which showed the typical signs ot the 
 disease. Becoming finally bedridden and nearly helpless, and showing some 
 mental changes, he was brought to the hospital. 
 
 On the ward he showed great memory defect, and could give scarcely any 
 dates of events in his life. He could place the date of his birth and marriage, 
 but had forgotten the dates of any of the positions he had held. Because of this 
 defective memory, he could not learn to play checkers, he did not care to read. 
 And he could only learn the simplest basket work. Alost of his activity con- 
 sisted in just looking about him at the other patients and at the nurses, and in 
 feeding himself at meal times. Though he could just barely move his hands 
 and otherwise had to be moved and taken care of, nevertheless he was always 
 cheerful, expressed himself as feeling well, and was certain of recovery. 
 
 d. Huntington s Chorea. 
 
 Progressive loss of efficiency going over to dementia, combined 
 
 with constant large choreiform movements. May show hereditary 
 
 tendency. 
 
 7, BRAIN TUMOR. 
 
 Dullness, with loss of memory and efficiency. May be convulsions. 
 Placid, contented type usually. May get excited, delirious state. 
 
 8. BRAIN SYPHILIS. 
 
 This is differentiated from General Paresis in that the process seems 
 more localized. The symptoms are confusion, or a delirious state, 
 auditory and visual hallucinations, memory defect for recent events. 
 Judgment, as a rule, good. The insight is present, and the patients do- 
 not tend to untidiness and delapidation, as do the General Paretics. 
 Further symptoms are headache, possibly focal symptoms, such as 
 paralysis ; cranial nerve involvement giving vertigo, deafness, optic 
 nerve changes, etc. Prognosis is much better than in General Paresis. 
 
 9. BRAIN ABSCESS. 
 
 Signs of infection plus those of organic brain disease, with or with- 
 out focal symptoms. 
 
 10. ''organic BRAIN DISEASE.'' 
 
 Cases in which no more definite diagnosis has been reached. ^lemory 
 defect, variation in judgment, possibly epileptiform attacks. Really 
 covers the whole group. 
 
 II. IDIOCY AND FEEBLE-MINDEDNESS. 
 
 Also called "arrested development." The causes are heredity or 
 birth injuries to the brain. It is a question if these disorders should 
 properly be classified here inasmuch as they are due to incomplete de- 
 velopment of the brain, i. e., to brain absence, not brain injury. 
 
 In these folk the brain develops only incompletely, consequently 
 there is every degree of lack of mental development to correspond. 
 Thus we have the idiots who are little above the beast, make uncouth 
 noises, have no understanding, can take no care of themselves ; 
 imbeciles, a little bit higher but not able to make a living, who have a 
 
MENTAL I >ISORDI;KS II 
 
 mentality ccjnivaler.t to that of a child between three and eight years 
 of age; morons, still higher but still of subnormal mentality, namelv 
 that of a child of eight to twelve years of age. 
 
 It is quite evident that people who are thus Feeble-minded or 
 Mentally Defective can never have the same sense of responsibility, 
 judgment, memory or efficiency as a normal person of the same age. 
 Yet they are still allowed at large because they have "always been that 
 way," and they work untold harm, having to be always supported by 
 others, raising large families of the same shiftless kind, frequently 
 turning to crime for a livelihood. 
 
 A large part of the daily work of the police force and jails is 
 taken up with these mentally defective and hence irresponsible crimi- 
 nals. Their irresponsibility and immorality and illegitimacy cause 
 them to be an ever growing menace. Many diseased prostitutes are re- 
 cruited from this class. 
 
 12. CONSTITUTIONAL INFERIORITY. 
 
 May or may not be allied to above. The old-fashioned term "atavist" 
 would come under this caption ; also the typical "bad egg'' or "black 
 sheep" of the family. Applied to those from whose heredity and social 
 status one would expect much, but who really seem lacking in moral 
 and ethical sensibilities, and commit all manner of indiscretions, even 
 crimes. This classification is often used to include the feeble-minded as 
 well. 
 
 The patient, who was a young man of good family, aged 23, was said by his 
 father always to have been "slow" in school, and in fact never had passed the 
 sixth grade, leaving at the age of 16. He had always been different from his 
 brothers and from the rest of the family who were successful financiers and 
 factory owners. Moreover, he was headstrong and self-willed and hostile to 
 advice, but could never make his own living. 
 
 At 18 he was sent South to work in a small town, but here he would con- 
 tinuall}^ get into fights with the men he had to deal with or take orders from. 
 Besides he w'ould drink and try to shoot up the town, trying to subdue all the 
 toughs in all the barrooms, though he himself was only the size of a weak 14- 
 year-old boy. 
 
 From here he was brought back to New York. He gave up drinking and 
 became a street-corner missionary. But he "preached Hell so hot" that the 
 other missionaries had him removed. 
 
 Then he married a girl of no greater mentality than himself, and was moved 
 off to a nominal job in another city, and was lost sight of. 
 
 II. Psychoses of Chemical Injury to Brain Tissue — or Toxic 
 
 Psychoses. 
 
 I. alcoholic psychoses. 
 Alcohol, as a toxic drug, causes so many and such characteristic men- 
 tal disorders that it is here given a place to itself. 
 
 (a) Pathological Intoxication 
 Drunken furor, the type in wdiich a man fights, beats his wife, mur- 
 ders, sets fire to houses, and usually has no memory of the events 
 afterwards. 
 
t2 MENTAL DISORDERS 
 
 The patient, a man of 42, a constant drinker, came home one night evidently 
 very drunk, and apparently extremely angry. He battered and pounded on the 
 front door as he was opening it. He cursed his wife and called her obscene 
 names. He picked up chairs and tables and smashed the other furniture and 
 mirrors with them, cursing at his wife the while, and hurling the fragments of 
 the furniture at his children. He finally upset the kitchen stove, bringing down 
 the pipe, and scattering the cooking vessels and the supper all over the kitchen, 
 roaring all sorts of broken bits of drunken obscenity. 
 
 At the police station the next day, he apparently had no memory of this 
 event, (amnesia). He said that he remembered coming home, but nothing more. 
 He indignantly denied the violence, and told the judge that, although he drank 
 frequently, he" rarely became intoxicated, and never to the extent described. 
 
 (b) DeUriuui Tremens 
 
 Generally comes after the patient has protracted his debauch until 
 he can no longer eat or sleep. No sleep and no food plus alcohol form 
 a disastrous combination. The characteristics are loss of sense of 
 present situation and persons; and at the same time the patient 
 imagines he sees and feels rats, mice, snakes, and other small animals, 
 generally black, crawling all about the floor, the bed, the walls, himself. 
 Often he is haunted by faces of the dead, or by a vision of the devil. 
 There is a very marked appearance of fear — the. patient seems to be 
 in the most horrible mental torture. Recovery generally takes place 
 unless other complications are present. 
 
 (c) Acute Hallucinosis 
 
 Is not quite the same as delirium. The patient knows the date, 
 where he is and the persons about him. But he imagines he hears 
 threatening or slandering voices, or he may see terrifying sights — 
 thinks the walls are falling in on him and he imust hold them up ; or - 
 that a team of horses is about to run over hhn, etc. Often with a 
 sardonic humor that causes him to lavigh at the same minute that he 
 is shuddering with fear (Galgen-humor) ; great mental anguish. 
 
 The whole hospital was aroused one evening by the sudden yelling of a 
 patient who had just come in the previous afternoon. When he was inter- 
 viewed he said that he had suddenly seen a team of two large, black horses 
 which were just about to run over him. 
 
 He was an alcoholic and had just begun to drink more heavily. He had been 
 having similar terrifying hallucinations for the past two days. 
 
 (d) Alcoholic Constitution 
 
 Habitual alcoholics become increasingly inefficient and unreliable. 
 
 There is both an intellectual and an ethical deterioration. Profuse 
 
 promises are made but never kept. Forgetfulness develops often with 
 
 precocious senility. Also suspicious states leading over to 
 
 (e) Alcoholic Paranoid States 
 Ideas of jealousy, persecution, or poisoniuii. In the Delusions of 
 Jealousy, a man will accuse his wife of infidelity, and will cling to this 
 idea in spite of all evidence to the contrary, openly accusing her of 
 going with other men. Not infrequently he will kill his wife when in 
 such a disordered mental state. ]\Iany murders have been committed 
 on this delusion as a basis. 
 
MKXTAL DISORDERS I3 
 
 Delusions of Persecution and Poisoning 
 The patient thinks that people are definitely against him to work him 
 injury-^much like the usual Paranoia, except that here there is a 
 definite alcoholic history leading u]) to the psychosis. 
 
 It is a question if there is not the same mechanism underlying both 
 forms. For we know that many cases of Paranoia represent a sub- 
 merged homosexuality which is denied to consciousness. In other 
 words, the fear is born of repressed desire. xA.nd the chronic alcoholic 
 manifests his homosexuality through this channel, not admitting it to 
 further consciousness, and not being able to ignore it completely. 
 
 The patient — a chronic carouser — had been married several years. He had 
 three children. One day he accompanied liis wife to a doctor's office, and there 
 he waited in an outer waiting room while she was being treated for varicose 
 veins of the leg. As the doctor and patient's w'ife emerged from his office, the 
 doctor handed her her garter. The patient inferred from this that the doctor 
 had had improper relations with her. He mentioned this many times to her. 
 Also, he implicated the parish priest. The man threatened to kill his wife and the 
 doctor, saying that he felt fully justified in doing so, and didn't care what hap- 
 pened to himself. 
 
 This man. also, no matter what jol) he held, sooner or later concluded that 
 some certain man on the job was against him or trying to get him discharged. 
 Thus both forms of the paranoid or delusional state were found in one patient. 
 Abundant evidences of submerged or unrecognized homosexuality were shown 
 in this man's record. 
 
 (f) Korsakoff's Psychosis 
 
 Loss of sense of date and place, great "holes in memory," with a 
 
 compensatory lying to fill in. Connected with nerve injury, causing toe 
 
 drop, etc. 
 
 FinalW alcoholism may be merely a symptom of some other under- 
 lying mental disorder. A psychopathic patient readily takes to alcohol 
 as a stimulant or refuge in a state of depression, or in case of inefiiciency 
 such as Dementia Precox or General Paresis. 
 
 2. DRUG PSYCHOSES. 
 
 All other drugs besides alcohol may also figure in drug habits. 
 
 (a) Drug habits may be regarded at times as a symptom of abnor- 
 mal mental states or of an abnormal constitution. The craving for the 
 drug seems to outweigh all other considerations whether of duty, 
 policy, responsibility, or consideration for others. This results in ex- 
 tremes of unreliability as regards his outward behavior. Any drug 
 may be thus used — opium, morphine, cocaine, heroin, chloral, ether, 
 chloroform. 
 
 In seeking the efifect of these drugs, the patient seems to be trying 
 to escape from unpleasant thoughts or situations of strain which trou- 
 ble him in moments of introspection, or which seem to hover on the 
 margin of consciousness. These painful ideas multiply as his dissipa- 
 tions continue, so that to the unpleasant thoughts or mental conflicts 
 which he originally sought to escape, are added the consciousness of 
 
14 MENT-AL DISORDERS 
 
 responsibilties shirked, promises broken, friendships violated, dutiei^ 
 demanding to be met. In short, he has beset himself with added dif- 
 ficulties of his own making so that the only spot of pleasure he finds 
 4s this drug which he seeks more and more. 
 
 This is the reason why the habitual drug user is not apt to give up 
 his drug, but rather to become ten times more an addict with each dose 
 he takes. The psychological side of alcoholism, as well as other drug 
 psychoses, is taken up in more advanced works. 
 
 The *'habit" is rather the result of a disordered personality which 
 remains constantly out of adjustment, and represents an evasion of the 
 conflict in his mind, or living a lie. The addicts are hence constitutional 
 liars and their consequent undependability and ethical deterioration 
 are only to be expected. Perhaps the individual prefers this combi- 
 nation to the discomfort of straightening out himself and the whole 
 situation. 
 
 Many interesting stories have been written pertaining to the state 
 of mind of these drug addicts. (See "Spy Rock," by Henry \^an Dyke, 
 "Confessions of an English Opium Eater," by DeQuincey.) 
 (bj Conditions resulting from accidental poisoning with these drugs. 
 
 These generally show comatose conditions (very heavy, deep sleep 
 from which the patient can only be momentarily aroused) or deliria — 
 patient loses knowledge of where he is, "wanders in his mind,'' sees 
 things, hears voices, imagines he is in very exciting situations, etc. 
 
 fe) Trade poisojiiug 
 
 This may be accidental poisoning, acute or chronic, with manifesta- 
 tions as above — coma, or delirium, or excitement. 
 
 (d) Illuniinating Gas Poisoning 
 Sometimes when a very great amount of the gas has been inhaled, 
 the patient after resuscitation is found to have great inpairment of 
 memory. Onl}- the most simple and usual things are remembered, 
 thinking is largely abolished, and ambition gone. The mental horizon 
 seems limited to the gratification of hunger, sex desire, and desire for 
 sleep. Physically he is well and may live for years in this animal state, 
 the brain injury being permanent. 
 
 (e) TJiosc caused by food 
 The most comimon is the caffeine psychosis in its mild forms, caused 
 b\- over-use of tea or coft'ee. It is characterized J)v restlessness and 
 impatience, desire to be on the go. dropping one half-finished task to 
 take up a new one, insomnia, and sensibility to slight sounds and colors. 
 In fact all sensibilities are much more keen and react to much finer 
 stimuli than normally. This sensitization is the reason why cafifeine, 
 in the form of coffee or tea, is so extensively used. It makes one feel 
 more alive, more awake, more keen. Fatigue is correspondingly 
 quicker in arriving, or if not, then when it does arrive is felt in much 
 greater proportion. 
 
MENTAL DISORDERS 1 5 
 
 Also to be mentioned are F^ellagra, and 
 Ergotism, acute poisoning — confusion or coma. 
 Chronic (from ergot growing on rye) — depression, drowsiness and 
 weakness, sometimes convulsions. 
 
 3. Mi:.\T.\L DISORDERS COMING FROM FEVERS (i. e. INFECTIONS), FROM 
 
 POISONS OF VARIOUS DISEASES, OR FROM EXHAUSTION- THE 
 
 TOXIC-INFECTIVE-EXHAUSTIVE GROUP. 
 
 These are usually considered together because the results of infection 
 are due to toxine and exhaustion also. 
 
 (a) From fevers and Infections 
 Commonest is delirium, slight lapse from normal; surest recovery. 
 Disorientation plus hallucinations are the characteristics of delirium. 
 
 A single woman of 34, whose past history shows a somewhat labile psychc- 
 pathic disposition and a tendency toward slight depression, began to show signs 
 of abdominal involvement — pain in the groin, tenderness over right lower 
 quadrant, septic temperature, and sweats. The appendix was operated, but the 
 signs continued. 
 
 Eleven days after the operation she l:;ecame fretful and excited, and soon 
 began to have visual hallucinations — thought people were looking through the 
 ceiling at her; that the house was on fire; that a man came and dragged her 
 about by the hair each night. , 
 
 She thought the hospital was her home, and that she was in her own bed. 
 She gave the month as April, whereas it w^as January. Immediately on examina- 
 tion she warned the doctor that there were people standing behind him to kill 
 him. She was easily recalled by a word or two from these. Hallucinations 
 plus disorientation indicated the presence of Delirium. 
 
 During the "Spanish Flu," or more properly Pandemic Influenza, 
 there were many cases of mental upset wdiich seemed due to the ex- 
 treme virulence of the toxine. A very excited form of delirium was a 
 frequent complication of the disease. 
 
 The patient was quietly lying in bed on the hospital porch which fortunately 
 was screened. He suddenly jumped up and yelled, "Police, police. Send a police 
 over here." To the crowd who immediately assembled in the street outside, he 
 3'elled, "They are trying to shanghai me here and send me away on a ship. Tve 
 got the Spanish Flu. Send a police here." 
 
 Other patients would get up and try to wander about or riui out of 
 the hospital, not knowing where they were. These excited cases 
 usually had a fatal termination. 
 
 Depression and fatiguabilitx' seemed to be a common result of the 
 infection, often lasting weeks. After the pandemic many cases were 
 referred for examination whose disorder was said to have been caused 
 by the Spanish Influenza. Certainlv many of these might merely 
 have been irupending and were immediately precipitated by the infec- 
 tion. Certainly, also, no such drastic toxine as that which characterized 
 the severe cases of the "Flu" would leave a person quite unscarred. 
 
 Depression with Fever or Infectious. In certain cases of grippe the 
 patient seems to have delusions of persecution and to think he or she 
 is mistreated. 
 
l6 ' , MENTAL DISORDERS 
 
 Transitory Memory Defect may sometimes result. 
 A Permanent Memory Defect is less common but has been known 
 to follow Typhoid or Scarlet Fever. 
 
 (b) Toxic-B^'haustwe Conditions, no fevers present, from Uremia, 
 Diabetes, or Eclampsia, (toxic condition caused by pregnancy). 
 
 Usually is just a deep coma. Or there may be delirium. Or accom- 
 panied by some confusion. There may be great restlessness or irri- 
 tability ; the patient may wander off and arrive in another city not 
 knowing where or who he is. The various laboratory tests known to 
 medicine will serve to differentiate and diagnose these conditions. 
 
 THYROID. 
 
 Cretinism. Congenital absence of gland — The child is born an idiot 
 with characteristic appearance of thick lips; protruding tongue, dull 
 expression and coarse, dry skin. The patient improves and becomes 
 almost normal on being treated with the gland, continually slipping back 
 into idiocy with cessation of the treatment. 
 
 Hyperthyroidism — "Grave's Disease'' — comes from over-activity of 
 the gland, and is much like the caffeine psychosis in its symptoms. 
 Patients are generally "worriers"; worry over everything, are ap- 
 prehensive, easily excited, sleepless, easily exhausted. Show rapid 
 heart and breathlessness. It is both toxic and exhaustive in nature, 
 the patient's muscles have less actual power because of the toxine. 
 
 Hypothyroidism — from underactivity of the g"land (also called Myx- 
 oedema) . Patients on the contrary to the above become lethargic, dull, 
 stupid, forgetful, inactive. They tend to become fat and pale and 
 doughy looking ; they always feel cold and sleepy. 
 
 (c) Exhaustive — from Extreme Loss of Sleep. InalDility to grasp 
 what is told, or remember ; loss of ambition ; irritability. There may be 
 delirium. 
 
 Exhaustion plus pain, especially in the old, often leads to delirium. 
 
 A man of 72, a bookkeeper, always a hard worker, met with a fracture of the 
 clavicle. This necessitated wearing a large plaster cast which was very uncom- 
 fortable, especially as it was hot svunmer time. The heat, the discomfort, the 
 loss of sleep, the pain from the fracture were the factors. He began to become 
 confused and forgot where he was. then would be taking part in imaginary 
 scenes, that is, became delirious. He was brought to the hospital and the 
 procuring of rest and easing of pain finally resulted in recover3^ 
 DEMENTIA FROM LACK OF SLEEP MAY OCCUR. 
 
 There seems to be a suspension of judgment and self criticismi and 
 regard for consequences, the patient may be easily suggestible and 
 commit wild acts and even crimes, 
 
 DISORDERS SHOWING FEATURES OF BOTH A. AND B. 
 
 (l) THE PSYCHOSES OF PREGNANCY 
 
 Are not a separate entity and are treated of in various parts of this 
 syllabus, but in response to request, they have been here gathered into 
 one group. They are of three kinds : 
 
MENTAL DISORDERS IJ 
 
 (a) Toxic, or more properly Toxic-Infective-Exhaustive. 
 
 (b) Psychogenic — entirely of psychic origin. 
 
 (c) Combined Type — showing symptoms of both the above two 
 
 types. 
 
 (a) Toxic-infecti<vc-exhaustive may be of renal or eclamptic origin, 
 ■or due to infection complicating the pregnancy. The psychoses may be : 
 
 Coma 
 
 Delirium with excitement 
 
 Convulsions may accompany either of the above and are a serious 
 
 sign. 
 
 (b) Psychogenic — Due to the fact of the pregnancy. These may 
 be of the type of symptoms described under 
 
 Hysteria 
 
 Anxiety Status 
 
 Depression 
 
 Manic-Depressive Psychosis 
 
 Depression with Suicidal Tendencies. This is a disorder the seri- 
 ousness of which is sometimes not realized until too late, when a 
 tragedy has occurred. 
 
 (c) Combined — Any combination of symptoms may and often does 
 occur. Viz., the toxic conditions may have hysterical symptoms super- 
 imposed, etc. Also, any imental disorder may be complicated by a 
 pregnancy. 
 
 TREATMENT. 
 
 It should now be realized that a mental disorder which means death or 
 insanity for the patient is as urgent an indication for the termination of 
 pregnancy as advanced pulmonary tuberculosis, or eclampsia. A toxic 
 psychosis merits no other consideration, unless very mild and of an 
 indubitably transitory nature. A psychogenic disorder likewise. 
 
 A Reactionary Suicidal Depression may be more rapidly fatal than 
 either of the above two previously recognized physical indications for 
 termination of pregnancy. 
 
 Practice will vary among physicians according to their beliefs, and 
 the fact that the woman happens to be unmarried will cause some 
 physicians to say "Hands off." though the patient end her life in the 
 next hour. \Miether the pregnancy is legitimate or illegitimate makes 
 no difference. It is time that we separated our double standard of 
 morality from our ideas of medicine. The purpose of medicine is to 
 save life. No man would impose on another man the death penalty 
 merely for illicit sexual intercourse. Nor should physicians for similar 
 reasons impose upon women what they would not impose u^x-^n other 
 men nor upon members of their own immediate families. 
 
 Accordingly, as soon as the diagnosis is definitely established, it is 
 my opinion that pregnancy should be immediately terminated, either by 
 
1 8 MENTAL DISORDERS 
 
 curettage or induced delivery, since delay gains nothing and may mean 
 death or a permanent psychosis which might otherwise have been 
 avoided. 
 
 POST PARTUM PSYCHOSES. 
 
 After delivery certain psychoses may develop. It may be difficult 
 to state whether they have been the result of the pregnancy or were 
 impending at the time. In some cases the psychosis may be referred to 
 the infectious group — the infection being a more or less mild "puer- 
 peral fever." Certain psychoses seem to have been impending and 
 occurred without regard to events just preceding their appearance, as 
 for instance a Dementia Precox which often develops without as well as 
 with so great a physical and serological change as pregnancy. On the 
 other hand a pregnancy may precipitate a psychosis, either toxic or 
 psychogenic, that might otherwise never have occurred. 
 
 (2) EPILEPSY CONVULSIVE ATTACKS. 
 
 The causes of epileptic attacks are not clearly established in all cases. 
 In some cases as above they are the definite results of brain disease 
 such as a tumor. In what is commonly called Epilepsy ("Idiopathic 
 Epilepsy") there seems to be no organic basis yet discovered which 
 could account for the convulsive attacks. These two types are marked 
 by loss of consciousness during the attack. The patient is apt to bite 
 his tongue and to wet or soil himself. The attack may come on at any 
 time, in any place. Others seem to be of the same type attack but com- 
 ing only in response to a certain highly charged emotional setting. 
 
 In some other cases the attacks seem to have developed entirely as a 
 symptom of Hysteria (Hitschman — "Freud's Theories of the Neu- 
 roses") so that some cases should certainly be classified under that 
 heading. The hysterical epileptic attacks often are not accompanied 
 by loss of consciousness, the patient as a rule remembers what goes 
 on around him or her. Whether most cases of epilepsy are approach- 
 able and remediable under that conception has yet to be discovered. 
 
 We do know, however, that most cases of the spontaneous epilepsy 
 do show a certain Epileptic Constitutiou or Epileptic Disposition. They 
 are as a rule restless, often habitually irritable, said by some to be con- 
 stantly trying to put forward their own views and draw attention to 
 themselves. This restlessness at times leads to extreme industry, and 
 epileptics have had, and do hold, extremely important positions. Napo- 
 leon, for instance, was an epileptic, and once while he was asleep during 
 an important battle it was said to be because he was having an epileptic 
 attack. 
 
 Their piety or religious fervor has been marked by others, and this 
 tendency towards religion seems to be more than a surface ritual, 
 but rather a part of their constitution. It is well known that just 
 before or after the convulsion, many epileptics feel as if they were 
 
MENTAL DISORDERS 1 9 
 
 related to God and had the same omnipotent power. I felt as if any- 
 thing I willed would have to take place," said one epileptic boy of his 
 feelings before an attack. A very good picture of this ecstasy is given 
 in Dostoieffsky's "The Idiot," which is the Russian term for epileptic. 
 The Christlike character of the hero, Prince Muishkin, is a good study 
 of the altruistic epileptic. 
 
 In connection with the omnipotent feeling of power, it is interesting 
 to note that three great world conquerors : Alexander the Great, who 
 sighed for more worlds to conquer, Julius Caesar, who conquered the 
 Gauls, and X^apoleon were epileptics. It shows what a man of great 
 intelligence with possibility for power may do if possessed of this 
 epileptic "I am invincible" type of mind. 
 
 The sudden discharge of energy characteristic of Epilepsy may 
 take place in forms other than the usual convulsions. These have 
 been termed "Epileptic Equivalents." Thus, in place of a convulsive 
 attack of unconsciousness, a sudden attack of violence may take place, 
 with forgetfulness of the whole occurrence afterward. Or the patient 
 may steal. Or he may suddenly and unaccountably drop everything 
 and wander away from homse, leaving family, friends and position, 
 without a w^ord to anyone. There just. seems to come to him an over- 
 powering impulse to imove on. These sudden wanderings are called 
 by the French "Fugues." 
 
 Sometimes sudden, periodic impulsive attacks of drinking are really 
 epileptic equivalents. The patient may go for weeks or months without 
 a drink, then suddenly he begins and takes one drink right after 
 another until intoxicated. He may be found by his friends in low- 
 resorts, or come to consciousness himself. After the attack he may be 
 depressed and self-accusatory and quite industrious and efficient until 
 the next attack. 
 
B MENTAL DISORDERS EXPLICABLE IN PSYCHOLOGI- 
 CAL TERMS— THE EMOTIONAL DISTURBANCES 
 
 e;motion guidks behavior. 
 
 If the preceding half of the book has dealt almost exclusively with 
 conditions that belong- to the realm of general medicine, this section 
 that follows is just as completely a matter of human nature and ever}- 
 day experience. 
 
 The psychogenic disorders are disturbances of the emotional nature. 
 They are a matter of personality, interest, tastes, development and 
 personal experience rather than a question of accidental injury or 
 disease. Their nature is personal and the active processes are per- 
 sonal, not external. We here deal more with the individual life and 
 less with an attempt to vary impersonal conditions. 
 
 When at any time we come to study the behavior of an individual, 
 we find that action is very largely the result of mood, or emotional 
 color or afifect — not a matter of pure, cold reason. To use a crude 
 example, we patronize a certain store because we have a warm glow 
 of cheery associations with that store ; we avoid certain streets be- 
 cause they are unpleasant to us. It is easier to buy a thing we zvant 
 than a thing we need. The successful salesman is very cognizant of 
 this and immediately seeks to establish pleasant relations with his pro- 
 spective customers — to interest them, to tickle their vanity, etc. So 
 that ^'Arousing Favorable Interest*' is the first step in salesmanship 
 as taught in the text-books and "salesmanship courses." 
 
 It is almost impossible to overestimate the role of emotion in our 
 everyday life and action. Many of the most important steps in a 
 man's or woman's life, viz., the choosing of a career, are made on a 
 basis in which emotion has a very large, if not the preponderating, part. 
 
 Let us consider the naive description given by Philip Jourdon of the 
 
 manner in which he fell in love with Cecil Rhodes — which led to his 
 
 becoming the latter's secretary and thus determined the course of his 
 
 life for years afterwards. 
 
 "It was about a year after I first met him that an almost uncoiitrollaI)le 
 desire took hold of me to be his private secretary and to travel over the world 
 with him. In my mind I had placed him on such a high pinnacle of fame that 
 such a wish seemed almost impossible of realization. Sometimes I felt I dared 
 not even think of it. It was my great secret and I did not communicate it to a 
 soul. I delighted to harbor the idea, and sometimes I would lie awake half the 
 night working myself up into a state of delirious excitement speculating on the 
 joy and pleasure which would be mine when I should be his secretary, when I 
 should be always with him and would go wherever he went. 1 had not then 
 received the slightest hint from him that there was even a possibilitj' o-f my 
 appointment as his secretary. 1 worshipped him and had an intense desire 
 to work for him and to please him." 
 
 20 
 
MENTAL DISORDERS 21 
 
 For Other examples, one need but consider the accounts of history 
 and hterature to see the power that that very subtle and complex 
 emotion which we call love has to influence the lives of people, and 
 through them even the destinies of empires. 
 
 And emotion is, in turn, essentially of the subconscious.''' Alade up of 
 inherited qualities, from pleasant or painful associations gathered daily 
 and hourly from the moment of birth onward they come suddenly out 
 of the dark domain of our mind to flood our consciousness and sweep 
 us over the barrier of cjuiescence into activity. We merely act be- 
 cause we want to — we dcAi't know why. We have been directed by our 
 subconscious. 
 
 The evolution of feeling outward into thought and action is neatly 
 described by Edward Carpenter : 
 
 "Feeling (or desire) lies beneath. Thought is the form which it takes as it 
 comes into the outer world. Let us take a definite instance. We desire to 
 travel. The desire begins first as a mere vague sense of discomfort or rest- 
 lessness ; presently it takes shape as a wish to leave home or to visit other 
 regions. It may remain at that for some time ; then it takes somewhat more 
 definite shape — as to go to the seaside. Then we consult our wife, we consider 
 ways and means, we fumble through Bradshaw, the thought of Margate comes 
 as a kind of inspiration, and a quite distinct and clearly formed plan emerges. 
 
 "Or we wish to build ourselves a house of our own. For a long time this 
 may only be a kind of cloudy pious aspiration. But at last and almost in- 
 evitably, the dream of the house takes shape within our minds. We get so far 
 as to make a pencil sketch of what we want. We go and prospect a site. We 
 consult an architect, and presently there emerges a much more definite and 
 detailed plan than before. Then steps are actually taken towards building. 
 Heaps of bricks and stone and other material begin to appear on the scene ; and 
 at last there is the house standing, which once only existed in the dream-world 
 of our minds. Always the movement is outward, from the indefinite vague 
 Feeling or desire to the definite clearly formed Thought, and thence to Action 
 and the External World." 
 
 So that we may say that action or behavior is largely a function of the 
 subconscious, its motive power being emotion. Probably most of our 
 behavior is a result of this almost automatic functioning. 
 
 The terms "normal" and ''abnormal" are arbitrary and indicate de- 
 gree of reaction — not kind of reaction. Because only when this auto- 
 matic behavior — our likes and dislikes, our loves and hates, our bold- 
 nesses and fears — are in general much like those of most of the people 
 around us, our social group, do we call it normal and accept it as such. 
 But codes of behavior vary greatly among different races. Oriental 
 and Occidental, savage and civilized, tropical and of temperate zone, 
 
 * (Whereas we will here employ the old distinction of conscious mind and 
 subconscious or unconscious-mind as if there were a sharp line dividing them, 
 nevertheless we must realize that what is subconscious or unconscious is con- 
 tinually becoming conscious in the form of memories, phantasies, imaginations, 
 and the like; and what is conscious is continually dropping into the unconscious 
 or subconscious, is being forgotten, and either takes place instantaneously. Con- 
 scious, semi-conscious, and subconscious are artificial divisions laid out on ©ne 
 continuous piece of material.) 
 
22 MENTAL DISORDERS 
 
 and just as much among the different social strata of the same race. 
 A gamin of the streets is brought up on a very different code than a 
 judge-advocate, a workman than a financial man. Herein perhaps Hes 
 much of the dissension in Hfe. 
 
 Now, "unusual behavior" or "abnormal behavior" is merely that 
 which is different from our usually accepted code, and varies widely 
 acccording to the code we adopt as standard. The terms are relative 
 only. Yery often behavior or action which may at first look very 
 queer, turns out to be very commonplace when we discover the person's 
 avowed purpose for so doing. For instance : 
 
 A young woman strolling one Sunday morning in the square about the 
 Washington Monument was suddenly struck by seeing a man half bowing, half 
 in a genuflection before one of the statues that adorn that vicinity. Imme- 
 diately she felt herself in the presence of a lunatic, and in some perhaps un- 
 guessed danger. In surprise and fear she clutched her companion and screamed, 
 "Look, Look !" pointing. The man then gravely turned around and the girl 
 finally saw that he had a kodak in his hands and had been merely trying to get 
 a good focus on the statue. The girl was so relieved that she collapsed on some 
 nearby steps, overcome with laughter. 
 
 Perhaps all behavior would in the same way be comprehensible to 
 us if we could see "clues to the workings of the individual's mind 
 behind it, i. e., if we could trace back of the action a familiar motive; 
 that is, one which we feel in ourselves. 
 
 In fact all abnormal behavior when subjected to analysis shows us 
 practically the same underlying forces at work as normal behavior, 
 being only extreme behavior, not abnormal. 
 
 But the point is that we often do not see these motives behind the 
 patient's actions, generally the patient does not himself. His behavior 
 taken broadly is merely reaction to stimulus and the reason that the 
 patient can not control his abnormal behavior is because he does not 
 control his normal behavior. It is our task, then, to increase our insight 
 into the patient's mind. 
 
 Therefore, in studying the psychogenic disorders, we wish to dif- 
 ferentiate the various forms of thought disorders or unusual thought 
 life as shown by their outward manifestation, namely speech and be- 
 havior. Then, bearing in mind that we are going to find the same 
 factors at work which activate ourselves, we try to discover as far as 
 possible the emotional state lying beneath these symptoms. Finally we 
 wish to arrive at the causes of this emotional state. 
 
 I. THE ELATION-DEPRESSION OSCILLATION' 
 
 Or Manic-Depressive Psychosis. 
 
 This seems to be an exaggerated form of reactions which are com- 
 monly found in normal life. All of us have felt elated at various times, 
 but in the course of a little while — hours or minutes, perhaps — the 
 extreme elation has diminished, and in a few davs or less all effects 
 
MKXTAL DISORDERS 23 
 
 have disappeared. If this elation keeps up in the heightened state for 
 days, or if it continues to increase and increase in intensity it becomes 
 a chronic elation or manic condition. 
 
 Likewise, depression which comes to everyone some time or other 
 in varying' degree and duration, if it tends to endure becomes an 
 abnormal state. And either elation or depression once established, 
 it is well known medically, might change very quickly into the other. 
 
 a. The Characteristics of approaching Elation, or Hypomanic 
 
 State. 
 
 The onset may take days or weeks, the patient's mood gradually be- 
 coming more and more excited. The patient begins to feel more keen, 
 more wide-awake, more active and efficient than ever before. He 
 feels a notable increase in his ability to calculate and to plan and to 
 handle a multitude of details (lifting of inhibitions). His mind seems 
 clearer and he can jump more readily from idea to idea, from plan to 
 plan. He needs less sleep than^^efore. Added to this he is elated; 
 he "feels fine," he "just touches the high spots," "business never went 
 so well before," "this is a fine old world," etc., (hypomania). 
 
 So far everything is to the good one might say and perhaps all of Us 
 should normally feel a little more keen, a little more active, a little 
 better able to handle our work. Perhaps also we would, if we were 
 doing only such work as we were intensely interested in and fitted for. 
 If the disorder stopped here all would be well and it has sometimes 
 happened that a large business has been developed by a man in this 
 hypersanguine state. 
 
 But to his friends and associates the manic patient begins to seem a 
 little too optimistic ; he may seem to overestimate his strength, his 
 gayety may seem a little more enduring than every occasion calls for, 
 his laugh may seem a trifle too frequent and too hearty. And this 
 soon continues beyond all bounds of doubt. Fantastic schemes are 
 entered into, gigantic financial projects are launched certain of failure; 
 the patient works feverishly day and night trying to bolster up the 
 colossal but insecure structures he has thrown up. 
 
 But it is no go and if he is not quickly taken care of the world comes 
 tumbling about his ears. The various impossible projects fail, credi- 
 tors appear, wild escapades bring' demands for retribution. This 
 state may be almost as disastrous for the time being as General 
 Paresis, but there are many redeeming features, the patient usually 
 remembers and can give an account of what he has done ; and recov- 
 ery usually takes place. 
 
 But what is the patient's behavior as the elation increases ? 
 
 CHARACTERISTICS OF MAXIC STATE. 
 
 He is very active moving alx)ut his room rapidly or talking away — 
 there seems to be great press of activity. It seems as if something 
 inside keeps him on the go. In his speech he shows a rapidity both 
 
24 MENTAL DISORDERS 
 
 of words and ideas, he jumps quickly from subject to subject, and 
 from word to word, apparently with but the most superficial association 
 from one to another. He can be easily distracted and his line of talk 
 shifted by any slight movement or noise about him. Viz. : if, during his 
 stream of talk keys are rattled, somewhat this result will happen : 
 "Millions — trillions — quadrillions — (keys jingled) keys — I've got 'em — 
 you've got 'em — keys to Heaven — God — Heavenly Father — angels — 
 golden hair — gold — money," etc. 
 
 He is extremely elated, self criticism has long ago been forgotten. 
 he laughs and makes noises and smiles at all about him. 
 
 At times a patient presents an irritable or ill-tempered mania — 
 hyperactivity, rapidity of speech with corresponding shallowness of 
 thought combined with irritation and combativeness. This is rather 
 rare. 
 
 Finally, much purposeless action, piore like playing, is the result. 
 He saves and files away pieces of paper, pages from magazines, etc. ; 
 decorates his room with all manner of bright objects, materials, and 
 wearing apparel. He, apparently in fun, miscalls names, gives all 
 around him fictitious names and titles, and goes through imaginary 
 scenes with them in which he himself plays the leading part. He is 
 an explorer, a conqueror, or a king. 
 
 The whole picture strikes one at times as play acting, and the 
 superficiality of thought association bears this out. The situation seems 
 to be a way of escape from some mental conflict which may or may 
 not be discovered on investigation. It is like laughing to cover em- 
 barrassment. 
 
 This reaction tends to recovery from the attack in most cases, 
 which may take place in a few days or not until after months. There 
 is very often a tendency to recurrence, and a fourth or fifth attack 
 is apt to be much slower at clearing up than the first or second. Elation 
 may alternate with depression. 
 
 (b) Depressi-on. 
 
 Here we have just the opposite picture to the above. Instead of 
 feeling happy, the patient feels always ''blue" or depressed. He is 
 quite inactive and does things only with greatest difficulty. Speech, 
 thought, and action are all slow. All his inhibitions seem increased to 
 an almost overwhelming degree. A decision seems sometimes impos- 
 sible for him to make. He will decide to go out and take a walk, get to 
 the door, and want to go back; then wish he were out on the street. 
 After much mental agony he may get out, then it is difficult to decide 
 what street to follow, or whether he should take a street car, and 
 which one ; or whether he hadn't better return at once ; but he should 
 get exercise, etc., etc. 
 
*MEXTAL DISORDERS 2y 
 
 In addition he may be very self critical and have ideas of his own 
 unworthiness and accuse himself of being a failure, unworthy, poverty- 
 stricken, a thief. He may think that through him the whole family 
 is reduced to poverty. 
 
 Just as elation or depression may readily change one into the other, 
 so also we sometimes find the symptoms of the two types intermingled. 
 
 The inaccessibility of the patient in either the manic or the depressed 
 phase would suggest that the. psychosis is a trick of the subconscious 
 to avoid some painful combination of thoughts ; and in this regard it 
 would seem to be a "protective insanity," rather than an "overwhelming 
 insanity." 
 
 A college professor who had all his life had periods of months in which he 
 felt particularly active and efficient — work went particularly well — alternating, 
 with periods of months in which work, especially new creative work, seemed 
 almost impossible. (Alild elated or depressed attacks, i. e., manic-depressive 
 constitution). At the age of 59 he felt constantly increasing difficulty in his 
 work until it linally seemed impossible. His attempts to resist this finally ended 
 in a fainting attack during some exercises in which he was taking part, and 
 from which he had to be carried. 
 
 Following this his depression was so well established that it necessitated his 
 removal to the hospital. On entrance he was quite despondent. He answered 
 only very slowly and after considerable pause. He tended to blame himself 
 very severely for matters which he had thought quite satisfactory at the time, 
 but in which he now saw cause for self-reproach, namely matters of admin- 
 istration, and some sexual conflicts. Memory was unimpaired, but the process 
 of recalling events was delayed somewhat b\- the slowness of association proc- 
 esses. Calculation was likewise delayed. Orientation was clear. The man 
 had clear insight. 
 
 After some months of this depression the mood began to change, the great 
 inhibition began to lift, his normal processes became more facile, and he began 
 to assume a normal appearance. This, however, lasted only a few days. Inhibi- 
 tions w^ere removed more and more. The previously deeply melancholy pro- 
 fessor became jolly, then elated. He became talkative, entertained his fellow 
 patients with risque stories such as he had never employed before. This elation 
 gradually increased until the manic phase was reached. The patient rose at 
 four in the morning, danced all day, w^rote innumerable epistles and haphazard 
 articles consisting of paragraphs of merely a sentence or two, or just a few 
 words. He wrote a poem to his wdfe w^hich had a rather presentable lyrical 
 quality. 
 
 After several months of this he became more and more quiet until a period 
 of normal mood and thought action were reached, in which condition he left the 
 hospital. 
 
 Mild grades of this manic-depressive reaction are called Cyclothymia. 
 In this the patient shows elation or depression which is beyond the 
 bounds of normal behavior but never reaches the extremes described 
 above. Sometimes, however, these abnormalities of mood and judg- 
 ment are overlooked at the time. 
 
 2. DEPRESSIONS APPARENTLY NOT OE THE MANIC-DEPRESSIVE GROUP. 
 
 (a) Those incidental to certain diseases, such as some heart condi- 
 tions, fatigue; convalescence from certain diseases — Influenza, Ton- 
 silitis, etc. These should be perhaps listed under the toxic-exhaustive 
 group, but there is probably a combination of both physical and psy- 
 
26 MENTAL DISORDERS 
 
 chogenic causes, i. e., the depression may be partly due to the weak^ 
 ness, but no less due also to the confinement, or to the inability to act 
 or think which is experienced. 
 
 (b) Depression with hallucinations, i. e., "seeing things" (visual), 
 or ''hearing things," usually voices, (auditory). The manic-depres- 
 sive depression is free from hallucinations, and their presence generally 
 indicates much more serious prognosis. 
 
 (c) Depression with paranoid trends, i. e.. Delusions of Persecu- 
 tion. In some cases these seem incidental to the depression and dis- 
 appear as the depression disappears. Prognosis here much better than 
 in Paranoia without depression. 
 
 A man of 52 entered the clinic, being markedly depressed and self-accusator}-. 
 He upbraided himself for having committed several sharp practices in business, 
 and stated that his wife was getting a divorce from him. He had always; been 
 of the manic-depressive constitution, either very jolly, or so depressed that 
 he would not speak to his family for a week. There had been several emotional 
 factors in his personal life, fear of having children, which neither he nor his 
 wife desired, fear of infecting his wife (he had acquired lues some years pre 
 vious), and recently a loss of potentia. 
 
 His depression continued and got worse, and he became more self-accusatory. 
 Soon he began to develop paranoid ideas : Because of his business dealings, he 
 was going to be sent to the penitentiary. Everyone in the hospital was in a con- 
 spiracy against him to arrange this. Whenever the doctor patted him on the 
 shoulder, it had some hidden meaning, though just what this was he didn't 
 know. 
 
 After some weeks the depression began to lighten and he became less despondent 
 and less self-accusatory. At the same time the ideas of the conspiracy againsc 
 him, the deep significance for himself which he attached to the actions of 
 everyone else, disappeared. The paranoid ideas had merely been a phase of, or 
 had been incidental to, the depression. 
 
 In some cases, however, the delusions seem more permanently es- 
 tablished. It is often difficult to differentiate these two types in order 
 to give prognosis until after long observation of the patient. 
 
 (d) Agitated Depression — more properly often the end stage of an 
 Anxiety Neurosis (see below). The patient is constantly weeping 
 and is apprehensive and is depressed. He or she accuses himself and 
 worries and is inconsolable. This forms a vicious circle: The worry 
 and self-accusation and sleeplessness cause the patient to be in turn 
 more worried, agitated and restless. 
 
 3. ATYPICAL EXCITEMENTS. 
 
 Excitements which are not typical of the manic excitement nor yet 
 showing deterioration. 
 
 A young man of 28 who came of unassuming laboring stock, had by dint of 
 much effort and thinking, raised himself above his surroundings to the extent 
 of becoming a broker's clerk. From there he changed to other offices, always 
 doing a good deal of calculating and dabbling in business deals. After several 
 months of over-time work, which kept him at the office until all hours at night, 
 he became excited. 
 
 On entrance to the hospital he was rather elated and smiled pleasantly as if 
 happy. He kept repeating, "I played the game to win. I played the game to 
 
MENTAL DISORDERS ' 2/ 
 
 win." But though he was elated, there was only slight flight of ideas, and there 
 seemed to be no press of activity. When addressed he would answer briefly 
 and smile, but would talk very little. 
 
 As the excitement abated, he became quiet and had more difticulty in answer- 
 ing, waiting an appreciable space of several seconds before replying. He took 
 little interest in amusements and light occupational work, and would sit for 
 hours in a lethargic state, semi-smiling, and following the nurse or attendant 
 about with his ej^es. This retarded condition persisted for some weeks. 
 
 We hence have in this case symptoms of the Manic-Depressive and also of 
 the Schizophrenic reaction types, but not conclusive for either. 
 
 4. PARANOIA OR DELUSIONAL STATE. 
 
 Delusions li'Jiich may be Perscciiiory, Grandiose, or Erotic.^ No 
 •^ Deterioration present. 
 
 The term paranoia is usually reserved for delusions of persecution, 
 but it really covers all the delusional states including the delusions of 
 grandeur and erotic delusions. A patient who has one delusion is 
 apt to have several, thus a patient who thinks everyone is against him 
 (persecutory) may be said to be grandiose in his self-importance. A 
 man with megalomanic or grandiose ideas, i. e., who thinks he is tre- 
 mendously wise or rich or powerful in the face of obvious evidence to 
 the contrary, may soon, because other people take the contrary view, 
 believe that everyone is in league against him. A man may think that 
 some very prominent woman whom he has never met is in love with 
 him, that he has a great attractiveness and a great power which she 
 r^els. Then an erotic and a grandiose delusion occur together. 
 
 ^ Xrhe classic picture is of a patient who thinks people are against 
 him, or are even making attempts on his life through poisoning or 
 causing accidents to happen to him, or there may be an organized move- 
 ment on foot to do him harm. (Persecutory Type). Everyone is 
 then pla^ceH in iHe hostile combine, and every occurrence of his life, 
 every person he meets, his words, actions, etc., all are _ given 
 special significance as being concerned directly with him. ; This is 
 the most difficult of all diseases to treat, as it is impossible to get the 
 patient's confidence and cooperation. For as a rule he places the 
 doctor immediately among his enemies, and this ends any further satis- 
 factory interviews.^) 
 
 Persons who have this form of disorder are often dangerous. It can 
 be easily seen that if the patient thinks a certain person is making 
 attempts against his life, he will consider the best plan is to kill this 
 person at once and so remove him from his path. Under such delu- 
 sions many murders are committed. Some authorities claim that 
 only those paranoiacs are dangerous in whom there is also deteriora- 
 tion but it is very difficult to draw the line here. 
 
 The patient, a man of 38, single, a mail-carrier, had always been seclusive, 
 without friends or confidants. He was the oldest of the family, there being a 
 younger brother and two sisters, and the patient was always domineering towards 
 them, especially the brother, and insisting on having his way. Of late years ho 
 
28 me:ntal disorders 
 
 had been very aggressive toward his brother, saying that he was trying to master 
 him. Frequently he would say, "You do anything to me and I will get you 
 for it." 
 
 He further thought that people along his route were planning something 
 against him, so that he had quarreled with every one of them. Moreover, he 
 had thrown rocks against the house of a certain girl cousin, and on one occasion 
 ^ad exploded a stick of dynamite on her doorstep. 
 
 It is impossible to say definitely whether this disease rests upon 
 organic disturbance or upon functional grounds, i. e., upon factors 
 which can be discussed entirely in the light of psychology. The bal- 
 ance of opinion seems of late years to favor the psychological inter- 
 pretation of the disease. Such patients, long before developing para- 
 noia, show a particular disposition. They seem inordinately welded 
 to their own ideas, and will not change them even after experiences 
 that would prove themselves wrong. There seems present a very ex- 
 aggerated self-importance and self-esteem, amounting to overwhelm- 
 ing self-love. This makes himself the center of all his attention and 
 hence, he judges, of other people's. The step from this self-importance 
 to feeling that people are persecuting him is easy. He regards him- 
 self so highly that he thinks others regard him with equal importance. 
 Everything that anyone says has a personal reference to himself (ideas 
 of reference). Soon he thinks that everyone must be jealous of him. 
 The origin of this self-love, or narcism, will be taken up later. Suffice 
 it to say here that it seems to be an mfantile reaction which gives a 
 feeling of comfort or pleasure, and is a way of escape from unpleasant 
 mental conflicts. 
 
 True paranoia (without apparent deterioration) is to be differentiated 
 from Paranoid Dementia Precox of which deterioration is an out- 
 standing characteristic. 
 
 5. DKMENTIA PRECOX. 
 
 Also called Insanity of Adolescence, or Schizophrenia. 
 
 The terms mean much the same. Dementia Precox means early 
 dementia; namely, a mental disorder coming on in overwhelming pro- 
 portions about at adolescence. Schizophrenia means a splitting of 
 thought-processes. This conception advances us little, however, beyond 
 what is covered by the term insanity or dementia, though it perhaps 
 would suggest a disorder not of structural origin. 
 
 Though the disorder is probably a matter of gradual development, 
 the onset may go unnoticed until the parents or friends are suddenly 
 surprised by a great and rapid change in the patient's personality. The 
 girl or boy may find himself unable to concentrate his attention on the 
 external world and to do any work that requires such attention. And 
 he may be equally unable to describe what is the nature of his dis- 
 order. In short, a very sudden and extensive confusion has taken 
 place. This is the full blown disorder. Hence it seems advisable to us 
 to describe the disorder in its earlier and less obvious stages. 
 
MI;NTAL DISORDERS 29 
 
 DEVELOPMENT STAGE OR PRE-DEMENTIA PRECOX. 
 
 It seems fair to embody this as part of the account since in most cases 
 the disorder has occurred in a certain definite type of personaHty — 
 called the "shut in," really "driven in," personality. The boy or girl 
 is introspective, subjective, his interest is apparently turned in on him- 
 self, he has no confidant to whom he can unbosom himself — 
 perhaps he feels so deeply that the feeling" is inarticulate. He prefers 
 to be alone rather than in company, is seclusive, shy, sensitive, easily 
 embarrassed. This description fits equally many youths of both sexes 
 who through the vicissitudes of development and education come to 
 adolescence unconscious of their forces, and unprepared for self 
 ■direction. One of the characteristics of adolescence is inarticulateness. 
 Some further unknown factor, however, seems to be necessary to pre- 
 cipitate the tragedy. 
 
 Another pre-Dementia type seems to include persons who, through 
 inferior nxental capacity, habitually bungle situation after situation, be- 
 coming discouraged and then more bungling and finally develop the 
 final condition described as Dementia Precox. 
 
 Any mental disturbance, then, in a young person during the years of 
 adolescence should immediately be regarded with the greatest serious- 
 ness. And a sudden change in personality occurring in a hyper-sensi- 
 tive and introspective girl or boy with inability to do any work (often 
 misconstrued as intentional unwillingness) combined with an inability 
 to explain his difficulty, is apt to be evidence of the presence of this 
 psychosis. 
 
 CHARACTERISTICS OF DEMENTIA PRECOX 
 
 These symptoms occur in a frequently changing variety of combi- 
 nation, and no description of the disorder is adequate unless it embodies 
 this idea of continual change from one picture to another. It must be, 
 as it were, a motion-picture in words. Four commonly occurring 
 phases or pictures or types have been used. But all the features of 
 one often do not occur together and sometimes one or more features 
 of other types may be present. The types are: 
 
 (a) Simple Type 
 
 (b) Hebephrenic 
 
 (c) Catatonic 
 
 (d) Paranoid 
 
 (a) Simple Type. 
 The patient who may have been a brilliant boy or girl gradually 
 begins to avoid company or the family, and keeps to himself. There 
 seems to be a gradual but very marked change in the personality. He 
 may sit for hours absorbed in day dreams, or reminiscences, or spin- 
 ning idle plans or fantasies which he does not try to carrv into action. 
 
^O , MKNTAL DISORDERS 
 
 It seems much as if the mental processes were blocked at the point 
 where they flow out into action, as if but endless reflection were 
 allowed. 
 
 He may be irritable or evidently worrying ; perhaps he cannot sleep 
 at night, and he alarms the family by arising and wandering about, 
 restless and unhappy. There may be sudden unaccountable outbursts 
 of weeping, or of excitement, or of temper. He may attach undue 
 importance to insignificant incidents, thinking that every remark he 
 hears is being made about him, whenever he sees anyone laugh that 
 person is laughing at him, etc. Further inquiry may elicit a history of 
 excessive indulgence in masturbation. This taken with the endless 
 fancies which result in no action would seem to indicate a turning in of 
 the interest on himself with a resulting loss of interest in making sorties 
 into the outside world. 
 
 To all questions he probably answers that he does not feel well, 
 perhaps he cannot name his difficulty. He may go to bed and spend all 
 his time there, and people remark on the strangeness of a person ap- 
 parently not sick, who can converse clearly, keeps track of days ar 
 current events, yet seems unwilling, though really unable, to do ar;y- 
 thing. 
 
 A young man of 21 was in the second year of college. He had always been 
 very sincere, serious, conscientious, and applied himself very studiously to his 
 lessons. He had always been interested in debating, but this usually meant a 
 great struggle between the things his intellect prompted him to say. and hi.^ 
 self-consciousness which hindered him from doing so. After a period of long 
 preparation for the critical debate of the year, he had been given the major 
 part for his side. Being suddenly overcome with self-consciousness, he made a 
 fizzle of his speech and lost the debate. 
 
 From then on he felt different. He was never able to concentrate on his 
 work, so that he did his lessons but very poorly. He was very self-reproachful 
 over this, but seemed unable to remedy it. He was troubled by frequent attacks 
 of drowsiness and his head ached frequenth'. His inability to concentrate or 
 to carry out any plans continued to be a source of discouragement to him, and 
 he was able only to spend his time in reminiscences and idle planning. 
 
 The type remains simple and recovery may take place, as long as 
 no fantastic changes have developed. That is, as long as it has not en- 
 tered any of the following phases. So that for practical purposes we 
 might speak of two types of Dementia Precox : 
 
 (i) Without fantastic developments 
 
 (2) With fantastic developments 
 
 The remaining types are commonly spoken of specifically and are 
 hence described. 
 
 (h) Hebephrenic Type 
 
 This reaction type is characterized by inability to concentrate on any 
 mental work and by an exaggeration of his usual traits with affectation, 
 superciliousness, or silly behavior. There is deterioration and develop- 
 ment of many odd ideas and actions without the appearance of either 
 the catatonic or paranoid reactions. 
 
MKNTAL DISORDERS . 3 1 
 
 PROGRKSS OF THE DISEASE. 
 
 As the disease procuresses we l)egin to get a more sinister picture. 
 Here hallucinations may a])pear, i. e.,,ima.i^ination of seeing visions or 
 hearing voices; or delusions, i. e., false ideas which the patient seems 
 Luiahle to correct in spite of abundant proof to the contrary, viz., he 
 ' may imagine his body has become an empty shell, or that he is in- 
 fluenced to act one way or the other. 
 
 He may see God in a vision or talk with Him, or he may feel him- 
 self gifted with divine power or entrusted with a diA'ine mission. 
 
 He may make many curious remarks which to him contain manifold 
 hidden meanings, or he may have a certain symbolic mark he puts 
 upon everything, indicating that this contains great hidden significance. 
 
 On the other hand sudden yelling or violence or an attempt to es- 
 cape may be carried on as a result of an inward prompting to make 
 some heroic effort and avoid some imagined catastrophe. 
 
 Complicating any of the above he may enter either of the following 
 states : 
 
 (c) Catatonic Type or Catatonic State. 
 
 This generally has a gradual development such as described under 
 Simple Type. 
 
 This catatonic state is characterized by a condition of muscular 
 rigidity, the opposing sets of muscles being kept taut and tense, and 
 the limbs being held rigid. This muscular tension is so persistent that 
 it gives a certain "waxy flexibility" to the arms or legs ; that is, if an 
 arm of the patient be lifted up by someone and held in an outstretched 
 position for a minute or so, then let go, it may be maintained in this 
 position for some minutes — often far beyond the time a normal person 
 would be able to maintain it in this position. 
 
 The rigidity seems to be an abortive sort of resistance on the part 
 of the patient against the disorder, perhaps against an indefinite some- 
 thing. Unfortunately this may be exhibited as resistance to the per- 
 son who is trying" to minister to his maintenance. (Sometimes when 
 the patient refuses food and drink, etc., it seems a definite attempt 
 towards suicide, as is borne out by other remarks and actions.) It may 
 be that this is an attempt to imitate the prenatal quiescence. Many 
 other characteristic symptoms have been noted, among them mutism or 
 refusal to talk, stereotypic or stereotyped movements which are re- 
 ♦ peated over and over and over hundreds of times w4th a machine-like 
 persistence. 
 
 There is the so-called Catatonic Stupor, in which the patient lies 
 
 • rigid, motionless in bed, day in, day out, night in, night out, refusing 
 
 to empty his bladder or allow his bowels to move. xA.ll functions have 
 
 to be carried out artificially — feeding is done by a tube, urine obtained 
 
^2 MENTAL DISORDERS 
 
 by catheter, etc. The patient is by no means in a stupor, though ; and 
 perception and memory are thoroughly keen and alert. This is demon- 
 strated by occasional remarks of the patient which show that he has 
 taken in all that has been said or done in his presence ; or when at some 
 later date the disorder seems to clear up for a time, and the patient 
 talks normally, and explains his experiences and behavior while in the 
 previous immobile state. 
 
 There is also the stage of Catatonic Excitement in which the patient 
 screams or suddenly does impulsive peculiar things. He may sud- 
 denly get up and jump out of the window, or smash something, or hit 
 someone. He may lie screaming for hours. Though to superficial ob- 
 servation he apparently cannot be reasoned with, the key to the situa- 
 tion seems to be that he acts in this way in response to an inner com- 
 mand or conviction. Perhaps he hears an imaginary voice telling him 
 to act in this way — a message from God perhaps. 
 
 The patient, a young man of 21, always bright, an honor man at college, 
 sensitive, idealistic, went through an experience which he described as feeling 
 like a "block in thought." He finally passed into the following condition. He 
 lay rigid in bed with eyes closed. He would not answer when spoken to except 
 occasionally to speak of his own unworthiness. He would not swallow food 
 when it was put into his mouth, and had to be fed by tube. His whole reaction 
 was a means of resistance to, or protest against, something in his situation, as 
 shown by the fact that he at times tried to throw himself out of bed on to the 
 floor on his head. With the exception of some remissions, when he would be 
 lip — though even then standing rigid — he continued in this catatoni:; condition, 
 being tube-fed and physically cared for. and after some months died. 
 
 (d) Paranoid Dementia Precox. 
 
 This type as a rule shows some premonitory symptoms, but there 
 may be a sudden onset with at once the appearance of this fully 
 developed picture. This type is characterized by the fact that the 
 patient presents delusions of grandeur or persecution which are more 
 or less systematized. It presents paranoia plus deterioration. Usually 
 he considers that someone is definitely working against him, perhaps 
 intending to poison him or kill him in some other way. He may think 
 someone is putting poison in his food and then refuse to eat or drink. 
 This is usually a serious sign. He often thinks everyone he knows 
 is con^bined in a "ring" against him. It seems as if the patient 
 thought that his mental difficulty arose because some individual is 
 influencing him through electricity, mesmerism, telepathy, wire- 
 less telegraphy, or practically any invisible influence that he ,has 
 heard of. 
 
 If he hears voices, they may belong to a certain person who is thus 
 directing him. Or these voices may call him names or talk slander- 
 ously of him. He refuses to refer his condition to his own disintegra- 
 tion or confusion but projects it, that is, he blames someone else for 
 his inability to think. The patient may get very angry at this [>erson 
 or persons he supposes are controlling him, and try to annihilate them. 
 
MENTAL DISORDKKS 33 
 
 Therein lies the danger from these eases. Always while they are at 
 large these patients are potentially dangerous. 1 lence the necessity of 
 permanent institutional care. 
 
 Paranoid Dementia Precox is differentiated from ordinary l*aranoia 
 by the presence of deterioration, and often also of hallucinations. In 
 true Paranoia there is apparently no other mental impairment outside 
 of the delusions themselves. 
 
 The patient, aged 26, was a yonng Jewish man, the son of p<jor immigrant 
 parents. The patient was idealistic, and strove in every way to improve the 
 family situation, being especially attached to his mother and she to him. He 
 early studied law, l)ut went to work as a stenographer for the B. & O. He 
 managed thus to help his family, and they moved from the slums to a nice 
 house near the park. 
 
 After being with the B. & O. some months he was discharged. ( Possibly his 
 deterioration had begim. ) He explained this, saying that a request had come 
 for criticisms of the railroad management, and he had written a letter to Presi- 
 dent Willard, stating that many office employees were doing only nominal work. 
 He never received an answer, and concluded from the actions of those abour 
 him that his letter had been referred back to his department head, that he had 
 been regarded as a trouble-maker; and that for this reason he was discharged. 
 
 For one and a half years following he tried to secure a position but was un 
 able to, though he saw many young men of no greater ability l)eing given jobs. 
 Hence he concluded that the B. & O. were trying to keep him from securing a 
 position. (This seems as if his capacity for work had suifered a severe change- 
 recognized by everyone but himself.) 
 
 He then decided to go to Hopewell, Va., but took the wTong boat down, he 
 thinks due to his having been influenced by someone. On arrival he was given 
 bare living quarters ; also he saw some men who he thought were detec- 
 tives shadowing him. And so he concluded that the munition makers were in 
 league with the B. & O. against him. Whenever a whistle blew, it was to make 
 his conscience trouble him. 
 
 He returned home and for five nights lay awake until he Anally saw that for 
 years an influence had been working against him. 
 
 At times a black spot was made to fall about him as he worked which his 
 fellow-men could see. He would have a vision of a certain figure before him. 
 All this was due to a scientific optical illusion brought about by the same con 
 spiracy against him. Moreover, he was made to have seminal emissions by the 
 same power, heard voices speaking in his ear. and was troubled by visions of all 
 manner of lewd sexual imagery. 
 
 After some months of this paranoia, plus inability to concentrate, he became 
 vengeful and wanted no one to enter his house. He threatened everyone who 
 came in. His family considered him so dangerous that they had him confined 
 to an institution. 
 
 I would impress upon the reader the fact that the above so-called 
 types are merely varying phases of one and the same very complicated 
 emotional disturbance, and that the distinctions betw^een them at best 
 are but very crude. The descriptions of all four should be taken to- 
 gether as the description of one entity. By reading them several times 
 together, common characteristics and a general relationship will grad- 
 ually appear so that when one type is seen, the possibilities of all other 
 types will be kept in mind. 
 
34 MKNTAL DISORDERS 
 
 DISCUSSION OF CAXTSES OF DEMENTIA PRECOX. 
 
 The theories to account for Dementia Precox are of two kinds. 
 
 1. The first type holds that the symptoms of mental disturbance 
 as shown by unusual speech and actions are the result of a toxine acting 
 on the cortex, or of actual changes taking place in the cortex itself, 
 either toxine or physical change being too subtle to be demonstrated 
 by our present laboratory methods. Abnormal secretion on the part 
 of the thyroid, adrenal, or the chromaffin system have been suspected, 
 also gliosis of the cortex. 
 
 All that can be said for such a theory is that as yet nothing definite 
 has been demonstrated ; though no doubt all would hail such a dis- 
 covery with great satisfaction. 
 
 2. The second theory is that mind or mental processes can suffer 
 a deterioration of themselves through faulty mental habits or faulty 
 development of instincts, or by being inhibited ; that is, that there can 
 be a functional deterioration of the mind itself. 
 
 The discoveries in the realm of the subconscious tend to show 
 that such a theory is possible ; discoveries such as the capacity of the 
 subconscious for retaining memories and for combining memories into 
 plans or inventions : and, on the other hand, the inhibition of thought 
 activity, the inhibition of the combination of images into plans and 
 the inhibition of the conversion of plans into action, by constellations of 
 painful memories, which may take place within its borders. 
 
 It is a theory of the functional development of Dementia Precox 
 which we ourselves wish to offer for consideration, not taking issue 
 with any other theories of the causation of Dementia Precox but 
 merely attempting to explain its development for a certain and perhaps 
 restricted group of cases. 
 
 The theory here maintanied m brief is this : The main feature of 
 Dementia Precox is that referred to as "deterioration" or "block in 
 thought," i. e., the inability to concentrate, and all other symptoms such 
 as mysticism, religious tendencies, symbolism, sterotypie, are conse- 
 quent upon this interference with thought activity ; and this thought- 
 blocking itself is due to a multiform and overwhelming inhibition 
 arising within the patient's subconscious. 
 
 As to the fantastic symptoms being secondary to the thought inter- 
 ference, we can see that religious cjuotations invariably refer back to a 
 lack of mental activity in the person who quotes, in this case the patient. 
 It is always easier to quote than to formulate the situation in words for 
 one's self. And as Biblical quotations form many of our earliest and 
 most lasting and most significant memories, when our own words fail 
 us in describing a situation, we reach into a memory pigeon-hole and 
 pull out a Bibhcal quotation to fit. Religious behavior is likewise 
 the result of scarcity of ideas for individual action ; though the col- 
 
MENTAL DISORDERS 35 
 
 ori ng of the religious behavior, whether it be ecstasy or abasement or 
 union with God, may perhaps be varied by emotional factors already 
 present. Stereotypic is certainly a result of lack of new ideas. Sym- 
 bolism is much like Biblical quotations in that it is the application of 
 a borrowed means of description in place of making one's own articulate-, 
 expression. 
 
 In this wa\' all fantastic developments, even hallucinations and delu 
 sions, perhaps may be a result of the thought blocking. The latter is 
 then the central feature of the whole picture and the one which we 
 wish to study further. 
 
 This blocking of thought we regard as a profound confusion, a ver\ 
 extensive inhibition, analagous to the milder inhibitions such as "stage 
 fright," lapses of memory, or repressions giving rise to the presence 
 of delusions. 
 
 The development of this blocking is the result of millions of experi- 
 ences dating possibly from the patient's birth. 
 
 A little more fully stated the thesis is that the human mind, sub- 
 conscious and conscious taken together, at infancy is like a very sensi- 
 tive plant. An unsympathetic environment which does not constantly 
 encourage its growth, and more, an outspokenly aggressive environ- 
 ment, acts on this sensitive plant causing many painful experiences and 
 memories. These in turn inhibit the growth of the delicate tendril-like 
 processes of the mind and distort the final growth of the individual. 
 Or expressed differently, the mind of the person is inhibited. 
 
 Thus as people grow up we get all grades of inhibition from the 
 ^'normal" person whose artistic capacities and means of self-expression 
 are hopelessly tied up, through the more inhibited types, the shy, the 
 diffident, the person who is too inhibited to carry on the average life, 
 to the still more inhibited. Now as the inhibition reaches an over- 
 whelming degree we say the patient has Dementia Precox and the 
 actions resulting from his inhibited mental processes we call the symp- 
 toms of the disease. There are mild types of the disorder, 'simple 
 deterioration," and a gradation all the wa\ to the very serious disso- 
 ciation of mental processes or deterioration which rapidly ends in death. 
 
 Let us illustrate by still further detail. 
 
 THE SITUATIOX. 
 
 Reducing the question to its simplest terms, it seems that wlicn we 
 analyze each of the various reaction complexes grouped under the 
 caption of Dementia Precox or Schizophrenia, we come upon essen- 
 tially the same underlying human drama. 
 
 First we find that the individual has always been somewhat diiterent 
 from his fellows. He has belonged to the "shut in" type described by 
 Tung. Instead of playing in the carefree, boisterous way of many 
 diildren, he has been shy and retiring, abhorring strife, very sensitive 
 
36 ■ MENTAL DISORDERS 
 
 to perhaps music and colors and the beauties of nature, all of those 
 things which we find in aduk life to be the stimulus to the artist. Being 
 different from his acquaintances, he has but few confidants, possibly 
 he has one, but here the friendship may be very intense. Abhorring 
 strife and the competition of children's groups, he keeps much alone; 
 in fact, he feels most at ease when alone. It is a question if he is 
 properly called the "shut in" type. He might perhaps be better de- 
 scribed as being "driven in" on himself — an introverted personality. 
 This may all be covered by an assumed shell of outer hardness, but is 
 apparent in varying degrees. 
 
 Many of these young people are intuitively altruistic and over-con- 
 scientious and responsible. They may carry the burdens of the world 
 upon their young shoulders, they may be filled with schemes to im- 
 prove life for many people, world improvement schemes, profundities 
 to which most people have grown callous with time. They are often the 
 over-sensitive, the over-gentle, the super-kind. 
 
 One gains the impression with many cases of Dementia Precox that 
 there are countless unexpressed desires and impulses wdiich are grop- 
 ing blindly for a way of expression, but never find it. In fact, the very 
 inarticulateness is one of the most striking characteristics of Dementia 
 Precox. 
 
 As a second factor in the development of Dementia Precox, we have 
 this sensitive, gentle, inarticulate person meeting an environment 
 which to him means death itself, death to the growth of nezi' ideas, 
 unusual hopes, "long, long thoughts," which we know are characteristics 
 of youth and childhood. 
 
 COURSE 
 
 To begin with, the play of children and their treatment of each other 
 is characterized by keen, struggling, almost cruel competition. The 
 domination of one child by another, the hostile criticism and teasing 
 of one child by one or all the others, brings the greatest pain to this 
 quiet, gentle type. 
 
 Then schools are manifestations of competition, the upper classes 
 against the lower, the older boys against the younger, the strong against 
 the weak. It must be confessed also that where all should be toler- 
 ance and patience and encouragement, i. e., at the hands of the teach- 
 ers, there is often arbitrary treatment. This has been well described : 
 
 "It seems to me that in our present mechanical, unimaginative routine of 
 'instruction' based upon exclusive objective ideals, we have an example of what 
 may be called the 'institutional neurosis.' The genus 'school ma'am.' conjuring 
 visions of an austere, puritanical female, policing formal rows of intimidated chil- 
 dren, affords us a familiar clinical symptom of this institutional form of re- 
 pression. In the typical preceptor with his overzealous emphasis upon stricture 
 and discipline, the psychoanalyst suspects that the real motive is some secret 
 discomfiture — some hidden discrepancy in the life of the teacher himself. And, 
 
MENTAL DISORDERS 37 
 
 in realitv, upon analysis, we find within him an overwcaning desire to assert 
 his own 'will, to coerce, to restrict, to repress the spontaneity of others. His 
 libido has been deflected from its primary, affectional sphere, to a regressive, 
 sadistic plane. Following" the introversion attendant upon his own disappoint- 
 ment, the contemplation of childhood fills him with l)itternoss and pain, and in 
 truth the motive that draws such an individual to the career of teaching is, only 
 too often, an unconscious resentment."* 
 
 So that this child feels himself overlaid by layer upon layer of more 
 or less hostile people, older than himself in years, and stronger in the 
 power to hurt and make life miserable for him. 
 
 From within, too, come further disturbing factors which conflict 
 with what he has been taught. 
 
 It is perhaps not exaggerating to state that only in the exceptional 
 case a child has his questions answered and is told freely and frankly 
 and wholly about many things. But especially rarely is he told about 
 sex and all its manifold and far-reach,ing radiations. Rather the 
 attempt is made to brush any knowledge or ideas of sex completely 
 out of his consciousness and out of his world. He is taught that he 
 should not think of it, much less know of it, and that there is some- 
 thing shameful connected with the whole subject. It is a subject on 
 which there should be no thought. And yet every child has some 
 glimmering of sex consciousness, some vague curiosity concerning sex 
 and creation, which seem incontrovertible, natural, and not only right, 
 but beautiful. 
 
 Again, perhaps the strongest influence of all, come the child's par- 
 ents. Many people see sometimes that the child seems hostile to his 
 parents, but often what is more truly the case is not seen, namely, that 
 parents are hostile at times to their children. This may be conscious 
 but it often is not. Now, that this statement may not seem quite 
 unfounded, we might quote the familiar observation that a mother 
 wishes to keep her children as infants, "tied to her apron strings," and 
 is jealous of their becoming interested in other women. 
 
 Now this would scarcely seem hostility on the part of the mother, 
 until the child or youth no longer wishes to remain an infant ''tied 
 to the mother's apron strings" and then the hostility appears. By 
 having his ambitions opposed (though perhaps not frankly so), hopes 
 quashed, and desires for liberty curtailed, he feels about him an iron 
 wall against his growth. His attachment for her also renders her 
 power over him all the more absolute. But this also he has been 
 taught to deny. 
 
 The father-son rivalry means no less an equal form of opposition to 
 the child. Though this may come to almost open warfare as the 
 youth begins to mature, in early childhood, and with >his "shut in" 
 personality, it exists chiefly in the form of domination of the father 
 over the child. We have all observed those sires who demand "imme- 
 diate obedience," who stress the patriarchal (and prehistoric) idea of 
 
 *Dr. Trigant Burrow-: "Permutations Within the Snhcre of Consciousness." 
 
 Jour. Abn. Psych. Aug.-Sept. 1916. 
 
^8 MENTAL DISORDERS 
 
 the dntv of the child to his parents, ignoring of course the duty of 
 parents to their children ; and we have perhaps deplored many times 
 the lot of those children who must give in to them in many unneces- 
 sary acts of discipline and almost slavery. 
 
 But perhaps the less obvious and for this reason the more deadly are 
 those fathers who do not oppose their children openly (for then such 
 children often develop into open rebellion and thence freedom), but do 
 so in less apparent ways. A'iz., when creative desires are derided, and 
 those very sensitive subjects, early creative attempts, are made light 
 of, treated as childish vagaries instead of the development of person- 
 ality, or treated with cold, absolute indifference. 
 
 Or parents may have their conventional ideas as to what people should 
 be, and try to compress these growing spirits to fit, to make a bush 
 into a fence post, a Pegasus into a cart horse. 
 
 The minds and interests and possibilities of children are so little 
 understood by their elders and the children are so often discouraged 
 by the obstacles set before them, composed of the lack of understanding 
 of their elders, that by the time the children reach adolescence, all spon- 
 taneity and originality has been pressed out of their consciousness. 
 It is fair to state that of all children, the majority are prevented by 
 their parents from developing to their greatest capacity. It is a very 
 rare thing that an interest in a child is strong enough to overcome the 
 opposition thus set up by the parents. 
 
 As Dr. Meyer puts it : • 
 
 "The greatest difficult}- in life, the greatest source of disharmony, (apart 
 from the influences of heredity, infectious disease, and poor feeding, and poor 
 chances for growth,) is the discrepancy between impulse, yearning and ambition 
 on the one hand and the actual opportunities and actual efficiency of performance 
 on the other." 
 
 The child, no doubt, seldom formulates this in his mind. The great- 
 est tragedy is that the situation does not get to his consciousness. He 
 is just disturbed without knowing why. Conscious wants may be 
 agonizing, particularly when active. As an artistic friend once wrote : 
 **To want to do, and to remain passive : to want to express, and to re- 
 main mute. This is perhaps the keenest suffering." 
 
 And yet here the want is at least conscious ; we know what it is we 
 want. But there are still deeper wants of which we are not conscious ; 
 when we want for something and do not know what it is. This latter 
 kind of want is the most disturbing as it is the least definite. Its verv 
 uncertainty adds bulk and distress. 
 
 The inarticulateness of the whole situation of Dementia Precox, the 
 vagueness of the factors, the fact that much of it goes on below the 
 level of the patient's clear consciousness, shows the deplorable state o1 
 a present day education which grants such a small degree of con- 
 sciousness to those within its domain. 
 
MENTAL DISORDERS 39 
 
 Now the child is very largely the resultant of the compression put 
 upon him by his environment, for his spirit is young, and tender, and 
 plastic, and he is just one alone; whereas his environment is old, and 
 set, and adamantine, and infinite. If a young plant be prevented from 
 growing in one direction by a stone set beside it, it can grow but in 
 three directions ; if it have a stone on two sides of it it can grow \ut in 
 two directions and upwards. But if a great stone be set on top of it, 
 it will grow^ greatly distorted, or it will not grow at all. 
 
 And so it is with the spirit of children. They present all gradations 
 of impaired development. Some personalities hit off a compromise 
 between what they desire and what is desired of them, and become 
 the usual ordinary, much inhibited, unoriginal person ; others become 
 hard and fight their way through to liberty, but they always carry scars 
 of this fight with them thereafter, and even pieces of their hardness 
 like bits of armor, which often surprise us years later by suddenly ap- 
 pearing in unexpected places. Now the individual variation among 
 various young spirits here enters ; the reaction is not alone due to the 
 impress of the environment, but the constitutional make-up of the 
 person determines to a certain extent also the result. The "shut in" 
 or more properly ''driven in" or the pre-Dementia Precox type is too 
 gentle, too kindly to fight. The stone placed upon him is too great. His 
 spirit cannot push it aside, and being thus pressed upon, it can only 
 grow distorted. 
 
 At adolescence, the child is overwhelmed by a surge of feelings and 
 desires and vague longings, which bring varying amounts of shameful- 
 ness according to his training and which, strive as he might he finds 
 himself unable to drive from his consciousness. 
 
 Though this is the period of budding forces he does not know what 
 he is interested in, what are hence his fortes, what line to follow. He 
 wants to do growing, budding, increasing things. Having been forced 
 for years outwardly to conform, he finally is unable to do otherwise. 
 But only outwardly. The universal spirit within, full of spontaneity, 
 interests, far-reaching visions, will not and cannot be denied. His 
 spirit is too new, too soft and bud-like as yet to fight its way out to 
 a clear view of the situation. In many ways he will be much attached 
 to his parents, and there will be great conflicts in him between wishing 
 to be as they mould him, to think as they direct, to try to deny those 
 ideas upon which they have placed the sign "forbidden." and his 
 inward conviction of what is true and there-fore right, the path which his 
 spirit points out for him to follow. In fact, it is this very morality, this 
 wish to obey those parents, as opposed to wdiat his sense of truth and 
 justice tells him, that causes the confusion : that is what Burrow means 
 when he says that it is ''an organic morality'' that fonms the basis of 
 the mental disorder. 
 
40 MENTAL DISORDERS 
 
 RESULT^ 
 
 Life, real life, mental life, is composed of stimuli — inspirations, 
 thou.f;hts, ideas — received and transmitted into acts. When these 
 thoughts, too great for expression or even consciousness, struggle for 
 expression and action, and this action is prevented, we get a distortion 
 of the spirit and of the personality. This disorder of all the impelling 
 and expressive factors of the personality in the extreme case are what 
 become known to us as the symptoms of Dementia Precox. 
 
 THE CHANGE. 
 
 The change in the individual becomes at last obvious, and there is 
 present an interference with the course of normal thought action, an 
 inability to do the usual work, to think clearly. In an intelligent intui- 
 tive person it is felt as a definite *'block in thought" — a certain some- 
 thing stops his flow of mental images and means of expression. A less 
 intelligent person may adduce reasons of his own for his behavior — he 
 may ''reason as he does." Owing to the automatic nature of behavior 
 these factitious reasons must be separated off from the picture. 
 
 A still less intelligent person projects it on to persons around him and 
 asserts that a "spell is put upon him," *'he is hypnotized," "electricity is 
 sent through him," etc. This may take place very rapidly with marked 
 excitement and appearance of fear, as if the change, though l)ut dimly 
 sensed, had frightened the person. This may often be the basis of the 
 Dementia Precox excitement and violence. 
 
 The catatonic has reacted to this feeling of sudden deterioration by 
 trying to fight it, the muscular tension and active resistance being 
 merely an evidence of the inward opposition to this unaccountable loss 
 of capacity. Excitement and violence may also be a sign of opposition 
 to this ovcrwhelnnng change. 
 
 One type of person mentally puts himself back in his mother's womb 
 to gain comfort that way and be new born ; to be "born again" in 
 order to return refreshed from this inability to think. 
 
 Another runs to religion and belief in God in just the same way — 
 (something stronger, all powerful, an ever-present help in time of 
 trouble). Christ may be the Mother image, and being Christ is bemg 
 the mother or being with her. For lack of ability to formulate and 
 express his puzzlement, he idly places symbol after symbol in a line 
 across the page. 
 
 All, in short, are seen to show more or less distinctly a feeling of 
 sudden loss of capacity, the individual reaction to this differentiating 
 the dift'erent types. The patient is completely overwhelmed by the 
 storm arising within his subconsciousness. The inward conflict be- 
 tween the desires he feels to be present and the teachings of his en- 
 vironment to the contrary, i. e., the social repression, between his dif- 
 fident hopes and memories of harsh experiences in attempting to real- 
 
MFCNTAL DISORDERS " 4I 
 
 ize them, causes his attention to be turned from the outside world in 
 upon himself; his attention becomes introverted. He turns from a 
 world which is practical, unsympathetic, painful, into the world of 
 his own thoughts wdiere no discordant criticism is raised, no dreams 
 forbidden. 
 
 His attention being little in the world about him, his behavior towards 
 it becomes purposeless, haphazard, and casual. He reverts to the 
 easiest adaptation to it or form of behavior he has memory of, infan- 
 tile or almost automatic action; perhaps he reverts even to the prena- 
 tal form of behavior, wherein he is nourished, warmed and clothed, 
 all with no movement or effort on his part. Thus we see why he keep*^ 
 to himself, why he wants to be let alone, to live in revery, to cease 
 from every form of activity. At last in the aberrant reactions ol 
 Dementia Precox he has found a long sought and eternal peace. 
 
 Truly did the old Cireeks say, "Those whom the Gods love (i. e.. 
 the kindly, the gentle, the loyal) die young." 
 
 Thus we see that in some cases the so-called Dementia Precox is. 
 like the neuroses, a disorder which arises in a certain type of person 
 as a result of a certain type of treatment accorded him by the indi- 
 viduals forming' his environment. Whv the individual is so con- 
 structed, and why others should treat him in this way are questions 
 only to be treated of in more advanced works. 
 
 A theor\- that shows us how inhibited states develop puts us one step 
 on the road toward preventing them ; and holds gut the hope to every- 
 one thereafter of a more full, more active, and more conscious life. 
 
 A few of the factors concerned in the causation of the disorder are 
 here touched upon ;, perhaps the future will bring to light many more. 
 
 11. The Neuroses or ''Xervousxess" of Apparextly Well People. 
 
 These states are quite diff'erent from any of the foregoing. For the 
 most part, they are not apparent to anyone but the patient or to those 
 who know the patient well. The patient can usually carry on his work 
 after a fashion and physically looks well enough, he sleeps well, has a 
 good appetite, and has the appearance of health, and a detailed medi- 
 cal examination fails to reveal any physical basis for the condition. 
 
 Pie himself, however, feels that he is radically prevented from doing 
 his work or acting or thinking with the ease that he may previously 
 have enjoyed. Pie may feel that he gets fatigued after a very short 
 time, and then feels "done up" for the rest of the day, or he is trou- 
 bled by vague feeling>^ of impending disaster, or is obsessed by the 
 feeling that he must viz.. count every white automobile that he sees. 
 The various symptoms have been grouped together and the various 
 symptom complexes designated as follows: 
 
42 MKNTAL DISORDERS 
 
 I. NEURASTHENIA. 
 
 The term, which means Hterally "nerve weakness," is appHed to 
 bodily conditions which seem characterized by irritable debility. The 
 patient is easily fatigued. He or she has a constant backache or head- 
 ache, and very little physical or mental activity is sufficient to increase 
 these aches to the point that they force him to stop and rest, or lie 
 down. Abnormal sensations are felt, or the reactions that normally do 
 not come to consciousness are perceived. 
 
 He may have a pain which moves about in the abdomen and travels 
 up to the heart, or to various places in the chest or back. The normal 
 peristaltic movement of his bowels may be felt by him to his constant 
 worrv. Irregular pains, backaches, headaches, burning in the abdo- 
 men, fatiguability ; symptom groups much like some of the thyroid 
 states are characteristic, hence the thyroid must be carefully inves- 
 tigated. 
 
 2. PSYCHASTHENiA (psychic wcakncss) used for conditions of 
 
 (a) Obsessive or compulsory thinking (obsessions) such as a 
 feeling of compulsion to count the numbers of houses when passing in 
 a car, a feeling that a certain thing is so when our better judgment tells 
 us it 15 not, etc. A man may feel that he has killed his brothci thotigh 
 he may know him to be alive, etc. 
 
 (b) Fear of some special situation or object {phobia). Fear of 
 open spaces, (agarophobia), fear of being in a closed room (clau- 
 straphobia), fear of dirt (mysophobia) . In the following we see a 
 phobia and an obsession : 
 
 A young woman of 19 had been married for a year to a young man of 21. 
 In all that time there had been no sexual intercourse as the patient had been 
 afraid. 
 
 For six months the patient had been very fearful of contamination and solici- 
 tous of washing her hands; she would wash them every few minutes. If she 
 saw a blind man, especially, she would turn right around on the street, hurry 
 home, and wash her hands. She had washed her hands so frequently, and with 
 such a strong disinfecting solution (sulpho-naphthol) that they were excoriated 
 for large areas. 
 
 3. HYSTERIA, a very suggestible state in which some intense idea 
 or emotion seems to result in an impairment of some part of the body, 
 such as hysterical paralysis of arm or leg, hysterical blindness, deaf- 
 ness, etc. These can be readily detected by medical tests as the neces- 
 sary structures are still intact. 
 
 Hysterical convulsions also may be the result ; and the basis of many 
 cases of epilepsy may be hysterical. 
 
 4. ANXIETY NEUROSIS ov Aiixictx Status. 
 
 Many cases of Neurasthenia are really cases of Anxiety Status. The 
 two merge imperceptibly and in short arise virtually on the same basis 
 and are the same disorder. The characteristics of Anxietv Neurosis 
 
MENTAL DISORDERS 43 
 
 arc feeling of apprehension, fear of some vague impending disaster; 
 perhaps anxiety attacks with rapid heart, breathlessness, weakness ; 
 uorrying, inabiHty to do one's best work. 
 
 Patient, a young man born in a small town in Virginia. As a boy always 
 shy, diffident, and seclusive, disliking rough games and vigorous sports. Military 
 school 15-16. but here very much alone and lacking confidants. After a few- 
 months* business course he went away from home to work in a strange town. 
 Here he lived in the apartment of some friends who were away. 
 
 Suddenly one night he had a heart attack — heart beat very fast and forcibly, 
 and he thought he was going to die. For two weeks he had several attacks, 
 ajways accompanied by fear. This was erroneously treated with Digitalis by a 
 local physician. After a month of this he began to fear leaving his house or 
 yard, and was afraid to attempt going anywhere for fear of another attack. 
 
 Finally he took an easy job in a local bank where pistols were kept. Then 
 suddenly he began to think, "What if I should kill myself!" Four months after 
 the original attack he began to have periods of depression in which he would 
 cry. 
 
 On entrance he was co-operative though slightly ill-at-ease or anxious. He 
 expressed himself as being nervous and at times depressed and afraid to do any- 
 thing out of the ordinary — afraid of going out and among people, under con- 
 stant fear of killing himself, so that at the sight of a razor or knife or sharp 
 article in a store, or on crossing a bridge he would think of suicide and fear 
 he might end his life. 
 
 Physically he was well ; his heart especially w^as normal in every way. 
 
 Course and development: Through free associations and analysis of his dream 
 material, his diffidence and fear of being with people were traced to a mas- 
 turbation complex and unrecognized homogenic impulses. IMother fixation also 
 played an important part. A gradual assimilation of these resulted in such im- 
 provement that he secured himself a position and advanced himsel ' from this 
 position to a better one. The depression disappeared, and the ideas of suicidt 
 retired to the role of mere fancies. 
 
 DISCUSSION OF' CAUSES OE NEUROSES. 
 
 Though it is, of course, not known what may be the future discoveries 
 in the domain of the emotional disturbances, nevertheless the more 
 recent psycho-analytic investigations have already shown us some very 
 interesting facts. In all the neuroses the real trouble is not that of 
 which the patient complains, or which exhibits itself as perhaps the 
 major feature. The difficulty is in reality at the antipodes, so to 
 speak, of the patient's personality. It lies not in a bodily ache, but in a 
 mental conflict. The bodily complaint or hysterical attack is ''played 
 up" automatically by the patient merely to take his attention from the 
 greater trouble, the mental conflict. 
 
 Bernard Hart's little book, The Psychology of Insanity, depicts in a 
 most engaging manner the common habit of avoidance of unpleasant 
 thoughts or unpleasant constellations of ideas. These unpleasant con- 
 stellations usually represent mental conflicts ; one part of us wants one 
 thing, another part the other. The struggle between the two becomes 
 so painful that rather than step in and take the extra pain of settling 
 it, we avoid the whole subject altogether and try to forget it. Through 
 a clear and simple explanation there is shown how this conflict and 
 evasion causes the changes in the individual's personality known as 
 
_|.| MENTAL DISOR:;KRS 
 
 the various symptoms of the disorder. Tlie so-called symptoms may 
 reallv be a protest of the patient's subconscious against the life he is 
 leading at the time. 
 
 Let us quote directly from another author the following : 
 
 "Whether it is a question of the vicarious impulses and imperatives '^rlouaing 
 to the obsessional state ; or of the characteristic somatic alternatives of hysteria ; 
 or of the mitigating substitutions and replacements constitutive of paranoid 
 mechanism, or of the organic equi\ ocations of the anxiety dissociations; or of 
 the exaggerated mood reactions presented in the temperamental subterfuge ot 
 cyclothymia, or of those manifold metabolic mimicries grouped under the ample 
 category designated by the popular misnomer of "neurasthenia" — under wliat- 
 ever alias the organism may seek to elude the demand most vital to it, at the 
 heart of the neurosis the essential situation is a moral revulsion. 
 
 "This revulsion is directed unfailingly against the admission of primary, 
 egoistic, organic, unconscious sexual trends. 
 
 "The essential moral situation present in the neuroses, the inherent conflict 
 of good and ill, is then the dominant picture in these disorders."* 
 
 In obsessions, that is, in the states in which the patient feels com- 
 pelled to do or to think certain things against his will as it were, he 
 takes refuges in these compulsive acts and thoughts from the painful 
 conflict of ideas. \'iz., by counting the numbers on every house he 
 passes, the patient avoids thinking whether he should replan his whole 
 life work. etc. In Iiystcria the niental conflict is converted into a bodily 
 change, viz., the action of an arm may be temporarily suspended and we 
 have what we call hysterical paralysis : or the action of the eyes is held 
 off, and we call it hysterical blindness ; of the ears, it being hysterical 
 deafness, etc. In this way the patient's subconscious attracts his atten- 
 tion to these symjitoms and away from his conflict. In the paranoid 
 states the patient puts his attention into self-love, self-admiration (self- 
 exaltation ) and thus takes his attention from trying to improve him- 
 self so as to gain the good graces of others. He says to himself they 
 are inferior, they fear him and hence plot against him. Or, and he 
 w^ill not admit this to himself, his fear is born of desire and he un- 
 wittingly loves them to such an extent that this repressed desire makes 
 him afraid of them. 
 
 In anxiety conditions the patient emphasises fears and apprehensions 
 to get away from his greater difficulties: so also in cyclotJiyniia or the 
 mild elatcd-dcpresscd reaction, the exaltation causes the patient to 
 think of outside objects rather than his inner thoughts. 
 
 The neurasthenic hides his conflicts in exaggerating his various 
 normal bodily sensations into s\'mptoms. Things which most people 
 pass by as being all in the day's course of events he magnifies to Gar- 
 gantuan proportions so that he need not think of liis complexes or 
 mental conflicts. 
 
 TREATMENT 
 
 The treatment of all those mental disorders listed under Section A, 
 that is those associated with cortical changes and general medical dis- 
 
 *Dr. Trigant Burrow. "Character and the Neuroses." 
 
MKXTAL DISORDERS 45 
 
 eases, falls within the doniain of internal medicine and can be studied 
 there in detail. In the main the princii)les are elimination of toxine, 
 conserv3tion of the vitality and. in some cases, specific ir.edicines to 
 cure the disease. It is best carried out in a psychiatric clinic which is a 
 unit of a general hospital, with the most favorable conduions of quiet- 
 ness, kindly nursing, medical and psychiatric care. 
 
 The treatment of the outspoken psychoses of Section B — those with- 
 out underlying medical disease, necessitates in many cases the facilities 
 of a hospital. The acute period of disturbance ideally treated should 
 be carried out with the patient fully isolated from the sight or sound 
 of other disturbed patients, and there should be an abundance of intel- 
 ligent and kindly nursing and medical attendance. 
 
 The expense of all this, however, precludes such conditions for most 
 people so that treatment of the majority of cases is carried out in in- 
 stitutions with varying numbers of patients to a ward. Here again the 
 keynote of treatment, in the acute stages particularly, should be kind- 
 liness so that tlie patient may come through his illness as quickly as 
 possible, and have onl}" his own internal difficulties to contend with, 
 these being quite enough without anything from the outside being 
 superimposed. Too many of our institutions, unfortunately, are run 
 on a basis of penology, rather than psycho-pathology; that is, the pa- 
 tient is punished in v^arious ways, including physical violence (sub rosa. 
 of course), for his uncompromising behavor. It is unthinkable to 
 expect a set of ignorant, poorly paid attendants to take an intelligent 
 view of such a complicated mental reaction as insanity. The introduc- 
 tion of trained nurses and better salaries and hours has been of value 
 in this. Perhaps these conditions are due to the universal avoidance bv 
 the public of all ideas dealing with mental disorder, based, it mav be, 
 on lack of knowledge of the subject. 
 
 After the disturbance has somewhat quieted dow^n, occupation is of 
 great benefit particularly the more primitive and fundamental hand 
 work such as the manual labor and interest of raisin^- a earden. the 
 gathering and cutting of wood for one's own fire, the making of 
 various articles of wood or other more artistic activities. As men- 
 tioned in the discussion of Dementia Precox, many such elementary and 
 artistic impulses are lying latent for want of opportunity in psychiatric 
 cases. In the abundance of time afforded in most cases, means of ar- 
 tistic expression may be developed through which the patient may main- 
 tain his equilibrium during the rest of his life. In all cases the environ- 
 ment should radiate normality and health and hope. The patient who 
 is recovering from a disturbance is often in a particularly sensit'ive 
 slate wherein a quiet environment with much outdoors has greatly to do 
 with aiding final recoverv. 
 
 Finally there should be a thorough sifting of the facts of the ill- 
 ness as complete as the patient has intuition- for. He should clarifv 
 
46 MENTAL DISORDERS 
 
 his ideas concerning his family, his relationship to each member of it, 
 the factors of his own makeup, his predilections and capacities, his 
 opportunities and activities. A further analysis should be made 
 whenever possible as to the emotional state underlying his disorder, 
 and the specific causes in himself of this actuating emotional state. 
 
 REST CURES. 
 
 Rest cures, after the manner of Weir Mitchell, do not now enjoy the 
 same praise that they did when first introduced a generation ago. 
 Foremost authorities now -consider that their indiscriminate use in 
 those many mild cases of emotional maladjustment or disorder, called 
 ''nervous breakdown," or ''nervousness" can be supplanted with a 
 more constructive form of treatment. 
 
 If the psychotic situation is considered to have come about because 
 of the effect of the environment's acting on a certain type of individual, 
 then a rest from this environment might be urged to have certain ad- 
 vantages. But to return the patient at the end of the period into the 
 same environment, without making any radical change in the environ- 
 ment, is merely setting the clock back a few days. The same result 
 will inevitably take place again. 
 
 And, moreover, to consider again the action of the environment on the 
 person ; some permanent effect or record has been made on the pa- 
 tient by this environment. The patient does not return to normal by 
 merely removing the environment. By no means. Every form of 
 matter has a very definite property of memory or ability to retain 
 impressions or records made upon it, and most especially the human 
 nervous system, not to speak of those subtler entities, the emotional 
 makeup or personality. 
 
 One might argue that, since life consists of stimuli received trans- 
 mitted into acts performed, a cutting off of the stimuli reduces the 
 action, and hence the v/ear and tear on the organism. But this is not 
 Dossible ; one cannot cut off all stimuli. We receive manv stimuli 
 from our surroundings, especially so from the wards of a hospital or 
 sanitarium. And apart from chese, our memory itself, as mentioned 
 above, not to mention our ideals, would supply us with stimuli for a 
 longer time than ever was contemplated for a rest cure. And to deny 
 an outlet to these stimuli has a disturbing and destructive effect on the 
 
 organism. 
 
 These patients suffer already from too little life ; from the fact that 
 they cannot convey their many stimuli into actions. They are already 
 confused or disturbed. This is the meaning of maladjustment. 
 
 Now, if instead of letting the patient lie idle in a virtual imprison- 
 ment, the time were taken up with an intelligent and painstaking analy- 
 sis of the whole situation, with a study of the underlying factors and 
 the makeup of the individual himself, the patient would be sent back 
 
MiiATAL DISOKDKKS 47 
 
 into the damajiing environment a new and different person, ihit 
 this is rarely done. Only the most superficial statements are made to 
 the patient. 
 
 To remove the stimuli completely, as the rest cure sets as its goal, 
 would be to reduce the patient to a state of such vegetable existence as 
 society shudders to place as tlie worst punishment upon its most 
 horrible criminals. It means, at the least, mental annihilation for the 
 period of the "cure." The patient then has to recover as best he may 
 from this annihilation. Failing" in this, and happily the cure does in many 
 cases, it means that just so much time is thrown away out of the pa- 
 tient's life. For here is the point: Constructive work, and only con- 
 structive work, will change either the environment or the person, and 
 hence the situation. 
 
 For the neuroses and milder managable psychoses already estab- 
 lished or about to be. Psycho-analysis, for those who are accessible, is 
 the remedy par excellence, and the only real remedy. 
 
 Where a patient has the least speck of intelligence, electrical treat- 
 ment for the neuroses or dilation of the rectum for hysterical attacks 
 belong to the same archaic stage of medical superstition as the burn- 
 ing of witches, or employing amber beads or horse chestnuts to pre- 
 vent arthritis. 
 
 Psycho-analysis is a setting straight of mental disorder, by tracing 
 back our thoughts to the deeper motives from which they have sprung 
 and thus getting at what really does actuate us. 
 
 The best way to do this is through the utilization of associative 
 material, preferably that of dreams, by taking each element of a 
 dream and tracing all of the associations in our mind until the thought 
 for w'hich this stands in sym.bolic form is found. Every dream, then, 
 is found to contain a hidden wish which for some reason or other we 
 would not admit into the full recognition — the lime-light — of our 
 attention. 
 
 Eventually one arrives at the emotions and instincts underlying our 
 behavior. This means long and painstaking work, for it deals with the 
 subtlest yet most enduring of material, namely, the personality : and 
 the slightest gain means an advance of the whole person into greater 
 development, a new life. 
 
 MEANS OF PREA'EXTIOX 
 For those psychoses of organic origin, the means of prevention con- 
 sist almost completely of those which enter into general medicine, in- 
 cluding hygiene, early treatment, moderate habits, life more in accord- 
 ance with the demands of our structure, free exercise and outdoor 
 play. 
 
 For those associated with industrial diseases there remains as the 
 only remedy the general country-wide elimination of those dangers 
 from trades. 
 
48 MENTAL DISORDERS 
 
 As to the psychogenic disorders, or disorders of emotion, they are 
 as indicated in the discussion of Dementia Precox, of social origin ; 
 that is, the lack of consciousness of underlying motives and emotions 
 and instincts on the part of society as a whole results in such treatment 
 of those who are quasi-conscious of these underlying forces that the 
 latter take refuge, in an abortive or compromise expression of what 
 they feel ; the abortive expression or compromise being known as the 
 mental disorder. 
 
 As general consciousness of these facts grows in society, mental dis- 
 orders of this type will diminish in the individual. 
 
 Specifically, a much freer, more individual, more personal, more 
 interesting form of education in the family and in the school, of the 
 parents and of the children, allows a completer, truer, sounder, clearer 
 mental development of those who follow. 
 
 REFERENCES 
 
 Dr. Adolf Meyer — Xofcs of Clinics in Psycho-pathology. 
 Dr. Bernard Hart — The Psychology of Insanity. 
 
 Fuudaniental Conceptions of Dcnicntia Praccox. 
 British Medical Journal, Sept. 29, 1906. 
 Dr. Trigant Burrow — The PsycJianalyst and the Conininnity. — J. A. M. 
 
 A., June 13, 1914, \o\. LXII, pp. 1876-8. 
 The Meaning of Psychoanalysis. — Jour. Abn. 
 
 Psych., April -]\ fay, 191 7. 
 llie Origin of the Incest Azve — Psychoanalytic 
 Review, July, 1918, \'ol. A^, Xo. 3. 
 Rabindranath Tagore — My School. — In the Group of Essays En- 
 titled "Personalitv."