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 UCSD Lib.
 
 Nervous and Mental Disease Monograph Series No. 9. 
 
 Studies in Psychiatry 
 
 Vol. I 
 
 By 
 
 Members of the New York Psychiatrical Society 
 
 NEW YORK 
 The Journal of Nervous and Mental Disease 
 Publishing Company 
 1912 
 
 Reprinted with the permission of the Original Publisher 
 
 JOHNSON REPRINT CORPORATION JOHNSON REPRINT COMPANY LTD. 
 
 1 1 1 Fiftii Avenue, New York, N.Y. 10003 Berkeley Square House, London, W1X6BA
 
 First reprinting 1970, Johnson Reprint Corporation 
 Printed in the United States of America 
 
 Copyright 1912 
 
 BY 
 
 The Journal of Nervous and Mental Disease 
 
 Publishing Company 
 
 NEW YORK
 
 In the early winter of 1903, Dr. Allen McLane Hamilton 
 invited a number of physicians to spend an evening with him for 
 the purpose of discussing the advisability of founding a society 
 for the promotion of the interests of psychiatry. This conference 
 was held and, as a result of it, the constitution and by-laws of the 
 Psychiatrical Society of New York were adopted on March 2, 
 1903. The Society has grown rapidly but has always retained its 
 original semi-private character. The meetings have been held at 
 the invitation of individual members, but any physician who has 
 shown especial interest or achievements in psychiatry is eligible 
 for membership. Since its foundation, four meetings a year have 
 taken place, at which original contributions have been read and 
 discussions carried on on various subjects connected with psy- 
 chiatry. Many of the papers have been published, but until now 
 no attempt has been made to collect them in permanent form. 
 When the question of publication came up it was found that an 
 issue of all the contributions would be too great an undertaking. 
 So some papers were chosen foi* publication now, while others 
 were left for subsequent volumes. 
 
 Pearce Bailey, Chairman, 
 Adolph Meyer, 
 George H. Kirby, 
 
 Publication Committee. 
 
 m
 
 LIST OF MEMBERS OF THE NEW YORK 
 PSYCHIATRICAL SOCIETY 
 
 Maurice C. Ashley Middletown, N. Y. 
 
 Pearce Bailey New York City. 
 
 SwEPSON J. Brooks Harrison, N. Y. 
 
 C. Macfie Campbell White Plains, N. Y. 
 
 L. Pierce Clark New York City. 
 
 Henry A. Cotton Trenton, N. J. 
 
 Charles L. Dana New York City. 
 
 *Emmet C. Dent New York City. 
 
 A. Ross Diefendorf New Haven, Conn. 
 
 Albert Warren Ferris Albany, N. Y. 
 
 Menas S. Gregory New York City. 
 
 Allan McLane Hamilton New York City. 
 
 Graeme M. Hammond New York City. 
 
 August Hoch New York City. 
 
 William Hirsch New York City. 
 
 Smith Ely Jelliffe New York City. 
 
 George H. Kirby New York City. 
 
 Phillip C. Knapp Boston, Mass. 
 
 Robert B. Lamb Fishkill-on-Hudson, N. Y. 
 
 ^Alexander E. McDonald New York City. 
 
 William Mabon New York City. 
 
 Carlos Macdonald New York City. 
 
 Adolf Meyer Baltimore, Md. 
 
 Flavius Packer New York City. 
 
 Stewart Paton Princeton, N. J. 
 
 Frederick Peterson New York City. 
 
 William L. Russell White Plains, N. Y. 
 
 Henry R. Stedman Boston, Mass. 
 
 * Deceased. 
 
 IV
 
 CONTENTS. 
 
 Page 
 
 The Insane in Japan. Dr. Frederick Peterson i 
 
 A Study in Race Psychopathology. Dr. George H. Kirby 9 
 
 The Curability of Early Paresis. Dr. Charles L. Dana 17 
 
 The Diagnosis of General Paresis. Dr. C. Macfie Campbell 41 
 
 Clinical Varieties of Periodic Drinking. Dr. Pearce Bailey 65 
 
 A Study of Some Cases of Delirium Produced by Drugs. Dr. August 
 Hoch 75 
 
 Remarks on Habit-Disorganizations in the Essential Deterior- 
 ations, and the Relationship of Deterioration to the Psy- 
 chasthenic, Neurasthenic, Hysterical and Other Constitu- 
 tions. Dr. Adolf Meyer 95 
 
 Constitutional Factors in the Dementia Precox Group. Dr. 
 August Hoch Ill 
 
 Comparative Psychological Studies of the Mental Capacity in 
 Cases of Dementia Precox and Alcoholic Insanity. Dr. Henry 
 A. Cotton 123 
 
 The Relationship of Hysteria, Psychasthenia, and Dementia 
 Precox. Dr. Adolf Meyer ISS 
 
 Ocular Reactions among the Insane. Drs. A. R. Diefendorf and 
 Raymond Dodge 163 
 
 Cyclothymia — The Mild Forms of Manic Depressive Psychoses 
 and the Manic-Depressive Constitution. Dr. Smith Ely Jelliflfe 193 
 
 Ocular Disc Changes in Dementia Pr^^cox. Dr. H. H. Tyson and 
 L. Pierce Clark 209 
 
 List of Papers Read Before the New York Psychiatrical Society. . 209 
 
 The Eye Syndrome of Dementia Precox. Drs. H. H. Tyson and 
 L. Pierce Clark 212 
 
 V
 
 THE INSANE IN JAPAN 
 By Frederick Peterson, M.D., 
 
 PROFESSOR OF PSYCHIATRY, COLUMBIA UNIVERSITY, NEW YORK 
 
 During a vacation spent last summer (1909) in Japan, I 
 visited a number of institutions for the insane, and through the 
 many courtesies of Professor Kure and Professor Miura of 
 Tokyo and Professor Imamura of Kyoto, I not only saw them 
 under the best auspices but was furnished with much informa- 
 tion in relation to psychiatry in Japan which I shall briefly put 
 before you. 
 
 The medicine of ancient Japan, like its art, literature and 
 religion, was derived from China by way of Corea. The earliest 
 Chinese medical literature which deals in any manner with in- 
 sanity dates from about 200 B.C. The earliest historical refer- 
 ence to insanity in Japan is contained in the law of about 702 
 A.D., which required the insane, epileptics, lepers, blind and 
 crippled to be given over to certain official caretakers, who on 
 taking such cases into their families were absolved from taxation 
 and civic duties. Between these dates and for some time later 
 Japanese physicians were guided in their study and practice 
 wholly by Chinese medical books, in much the same manner as 
 the Europeans for centuries acted only on the authority of Hippoc- 
 rates, Galen and the Arabian writers. Insanity and epilepsy are 
 well described in the first Japanese book of medicine, the " Ish- 
 inho," appearing in 982 A.D, For several centuries after this, 
 medical treatment fell chiefly into the hands of the Buddhist 
 priests who practised only with magic and prayer, until the period 
 between the seventeenth and nineteenth centuries, when medicine 
 reawakened and the Japanese physicians out-distanced in all re- 
 spects their Chinese progenitors and contemporaries. The treat- 
 ment of insanity during this period did not differ much from that 
 of the more ancient day, and consisted chiefly of the sweat-cure, 
 catharsis, emetics, thermocautery with moxa, hydrotherapy, acu- 
 puncture and at times blood-letting. The needle and moxa as 
 2 I
 
 2 THE INSANE IN JAPAN 
 
 counter-irritants have for ages been favorites of both the Chinese 
 and Japanese in all manner of diseases. Hydrotherapy, described 
 in Chinese literature as long ago as 200 B.C., has always been a 
 preferred method of treatment among the Japanese. Its use in 
 insanity is described in the first Japanese book of medicine 
 already referred to (982 A.D.), 
 
 In old times the insane were for the most part kept in families, 
 the milder cases taking part in work on the land, or in the in- 
 numerable household crafts of that people. If subject to periods 
 of excitement mechanical restraint was used, anklets, wristlets, 
 chains, and solidly built chambers attached to the paper houses. 
 Often in the country the patients were blistered on the soles of 
 the feet to make them disinclined to run away. 
 
 A kind of family care grew up gradually, sometimes evolving 
 into a colony system ; and many private asylums were established 
 long before any public asylums such as we have in the West were 
 created. 
 
 Along in the early eighties the first public asylum in Japan was 
 organized and established at the present capital, Tokyo. It was 
 constructed somewhat on German lines, but with due regard to 
 the necessities of earthquake architecture, for in a country where 
 an earthquake is almost an everyday occurrence it is essential to 
 build wisely. The Tokyo asylum consists of a series of one- 
 storied pavilions scattered in a considerable park. The German 
 traces in construction and arrangement are of course due to the 
 fact that the foremost Japanese physicians of that day had taken 
 their training in Germany, and the medical profession was wholly 
 directed in all its undertakings by German influence. Now- 
 adays with several universities of their own and a goodly num- 
 ber of medical faculties, quite equal to any in the world, in which 
 all of the professors and the tongue spoken are Japanese, they 
 need not go abroad for medical study. 
 
 In the older buildings of the Tokyo asylum the usual western 
 corridor system prevailed, with numerous single rooms, but as 
 time went on they began gradually to remove partitions and to 
 convert the series of single rooms into good sized dormitories. 
 This was the more readily possible because there seems on the 
 whole to be less excitement among the Japanese insane than 
 among the insane of other countries. The extraordinary quiet-
 
 THE INSANE IN JAPAN 3 
 
 ness of asylum wards in Japan has been commented upon by 
 other foreign visitors. It doubtless depends upon that imme- 
 morial training in the repression of emotional expression which 
 is so noticeable a feature in Japanese psychology. 
 
 In some of the newer pavilions they have European bedsteads, 
 tables and chairs, but for the most part the furnishing is Jap- 
 anese, thick mattings upon the floors, thick quilts laid upon these 
 mattings for beds and tiny dwarf tables when such are needed, 
 with no chairs or other furniture. 
 
 The asylum is lighted by electricity, electric lighting being 
 a specialty of the Japanese everywhere at present, owing to un- 
 limited waterpower in innumerable mountain torrents which have 
 been harnessed to do this work. There is provision for the daily 
 hot bath for every inmate according to Japanese custom, for 
 every man, woman and child in Japan takes at least one hot bath 
 a day, and sometimes two or three ; and our western systems 
 of plumbing for bath and toilet purposes have been adopted 
 and installed. There is provision also for the prolonged bath 
 which has so much vogue with us at present in the treatment 
 of the insane. 
 
 Much is made of occupation. The laundry and garden work 
 are done by inmates. There were rooms in which patients were 
 weaving, plaiting straw, making paper envelopes, and carrying on 
 other crafts. 
 
 All the buildings were airy, neat and clean, and to me a strik- 
 ing feature of the care of the insane was the morale of the nurs- 
 ing staff. I believe such gentleness, kindness, patience, and 
 assiduous attention to the sick could be found nowhere else, for 
 nowhere else exists a whole race of people who never scold, 
 quarrel or manifest impatience, but always turn a smiling face 
 and extend a helpful hand to one another. This other fact in 
 Japanese psychology I observed among all classes throughout my 
 visit. It was particularly noticeable where I least expected it, 
 among the lower classes. 
 
 The insanity clinics of the university are held here and the 
 laboratories of the asylum are well-equippd with pathological 
 and psychological apparatus. Elaborate histories of the patients 
 are taken and besides the director, Professor Kure, there are ten 
 physicians working in the hospital whose capacity is about 500
 
 4 THE INSANE IN JAPAN 
 
 beds — a capacity of one to fifty. We are lucky in New York 
 State to have one physician to two hundred patients. 
 
 There can be no overcrowding in the Tokyo asylum, for 
 according to law a new patient is only admitted when there is a 
 vacancy. An indigent patient brought before the authorities is 
 sent at public expense to one of the seven private asylums in 
 Tokyo if the government asylum has no bed. These seven 
 private asylums have a capacity of about one thousand beds 
 between them. 
 
 The method of commitment is simple. When a case of in- 
 sanity develops, a member of the family reports it to the police. 
 A doctor then goes to the house with the police officer to examine 
 the patient and reports his findings to the head of the police who 
 issues an order of commitment. In the country a governor's 
 certificate takes the place of police commitment. There is never 
 any effort on the part of patients to escape. 
 
 The Tokyo institution has one of eleven psychiatric clinics in 
 Japan. I believe we have not so many in the United States. 
 There are psychiatric clinics at the three universities Tokyo, Nag- 
 asaki and Fukuoka, and at the medical schools of Okayama, 
 Kawazawa, Kyoto (two medical colleges), Nagoya, Shibu, Sendai 
 and Osaka. 
 
 As regards the character of the cases observed in Japan, there 
 are several interesting points. In the first place the classification 
 approximates very closely to ours and we observe large numbers 
 of cases of dementia prgecox, manic-depressive insanity, general 
 paresis, and the like. True paranoia as we know it is a great 
 rarity. On the other hand general paresis and dementia praecox 
 are more common than with us. At the Tokyo asylum the 
 proportion of cases of general paresis from the years 1887 to 1901 
 was 15.86 per cent. 
 
 In a country which has no opium or alcohol vice, inebriety 
 cases are rare. Only 6.65 per cent of the admissions of men 
 presented mental disorder due to alcohol. A case of alcoholic 
 insanity in women is almost unknown. Very few doctors in 
 Japan have even seen a case of delirium tremens. Korsakoff's 
 psychosis has not been observed. The alcohol cases are due to 
 sake, a mild kind of sherry-flavored wine, derived from rice. 
 Only the lower classes drink sake to excess, and very few of
 
 THE INSANE IN JAPAN 5 
 
 these. Temperance societies are growing rapidly in Japan. In 
 Formosa, a province of Japan, considerable opium is used, but 
 scarcely any in Japan itself. There are no cases of Indian hemp 
 or cocaine inebriety. I noted a considerable number of cases of 
 insanity wholly new to me, viz : psychoses associated with Kakke 
 or beri-beri. The multiple neuritis and mental symptoms made 
 a picture something like that of Korsakow's psychosis. In our 
 western books on nervous diseases, mental symptoms are not de- 
 scribed at all as associated with beri-beri, but in Japan we have 
 a beri-beri psychosis which reminds one partly of pellagrous in- 
 sanity and partly of the Korsakow syndrome. 
 
 I come now to the most interesting part of my journey of 
 observation in Japan. 
 
 About seven miles from Kyoto, one of the ancient capitals of 
 Japan, lies the village of Iwakura, to which one day Professor 
 Imamura, professor of Psychiatry in the University of Kyoto, 
 conducted me. It is alone well worth going to Japan to see. I 
 believe I am the second westerner who has been there, the first 
 having been Dr. Stieda of Russia who mentions it, and calls it a 
 Japanese Gheel in an article on " Psychiatry in Japan " in the 
 Centralb. f. Nervenh. und Psychiatric for 1906. Professor Ima- 
 mura has himself described it in the Transactions of the Inter- 
 national Congress of Psychiatry, Neurology and Psychology, 
 Amsterdam, 1907. But it deserves to be better known, for as an 
 ideal place for the care of the insane it is unique, there being 
 only one other institution for the insane that I know of that in 
 anyway embodies what should be our own ideal as far as con- 
 cerns surroundings and construction, and that is the Maison de 
 Falret at Vanves in the outskirts of Paris. 
 
 The third daughter of the Emperor Gosanjo in the eleventh 
 century developed melancholia in her eighteenth year. Word 
 was brought to the imperial household that at Iwakura was a 
 holy fountain the water of which was healing to mental diseases 
 and to disorders of the eyes. The Emperor's daughter was taken 
 there nearly 900 years ago and recovered and so brought fame to 
 the temple and the well of Iwakura, as a result of which the in- 
 sane were brought there in great numbers. At first three small 
 inns were constructed to receive them, then later tea houses and 
 villas and cottages sprang up in which to care for the ever in- 
 creasing influx of patients.
 
 6 THE INSANE IN JAPAN 
 
 In the year 1889 the village had 239 houses, with 1,579 in- 
 habitants, and up to that year one to two patients were received 
 into each family to share in the occupations of the household 
 which were chiefly out of door employments in fields, gardens 
 and forests. 
 
 The village lies at the foot of great hills, in a beautiful wide 
 valley. The hills are covered with evergreen cryptomeria pines 
 and spruces, while the valley is cultivated every foot of it with 
 rice and vegetables. Each little house has its own idyllic charm. 
 This charm lies in its simplicity of architecture, harmony with 
 the landscape, and in its well-studied gardens both inside the 
 court-yard and outside around the house. Paper windows and 
 removable paper walls insure light and air and a practical out-of- 
 door life night and day. From the spotless mats upon the 
 floor across the spotless verandahs one looks out upon the gardens 
 green with pines and cedars all the year round, with flowering 
 shrubs for every month between the winters, looks out into the 
 restful gloom of the giant cryptomeria woods on the one side, or 
 across the valley of rice-fields to the evergreen hills upon the 
 other. There are beautiful paths and roads among these cedar 
 forests, and several imposing temples among them. 
 
 In 1889, the Japanese government, evidently under the im- 
 pression gained from a study of the asylum systems of Europe 
 and America came to the conclusion that their colony system that 
 had grown up so naturally was too far from our western ideals, 
 as exemplified in our colossal caravanseries for the insane, and 
 so forbade the insane being any longer taken to the village of 
 Iwakura. They abolished the method as probably barbarous, just 
 as at one time they abolished cremation, having been persuaded 
 by Europeans that it was heathen practice, but returned to it again 
 when they learned that cremation was the goal to which western 
 civilizations are tending in the method of disposal of the dead. 
 
 The result of this opposition of the government has been to 
 reduce at least temporarily the number of insane in the colony. 
 It is altogether likely that as soon as the authorities learn that out 
 of themselves they have developed through nearly a thousand 
 years the best of all methods of caring for the insane, toward 
 which the West itself is struggling with much difficulty, they 
 will remove the proscription and restore Iwakura to its ancient
 
 THE INSANE IN JAPAN 7 
 
 rights and privileges under state organization and inspection. 
 There is one retreat for about 90 patients at Iwakura built on 
 European models under the care of physicians, to which excit- 
 able cases may be brought from the family homes in the neigh- 
 borhood. 
 
 I have already referred casually to the Maison de Falret, a 
 French asylum in the suburbs of Paris, and in connection with 
 the results of my visit to Japanese institutions I cannot forbear to 
 mention it again and to say a few words about a place that is 
 probably unknown to most of my hearers, because after all the 
 chief value of any observations by a traveller must be the new 
 knowledge, the example, the lesson or the moral that he brings 
 home to his own people. Doctors Voisin and Falret two special- 
 ists in psychiatry nearly one hundred years ago, purchased an 
 estate of over sixty acres in the environs of Paris, made of it a 
 park, and planted it well with trees and shrubs. A pretty stream 
 courses through it. They built therein small houses or bunga- 
 lows, each surrounded with high green hedges and pretty gar- 
 dens with its own gateway. Now after a hundred years it 
 realizes their dream of what should be done for the insane. It is 
 a large park with magnificent trees and shrubbery, divided into two 
 halves by a farmstead group, thus making practically two parks, 
 one for each sex, and there are twenty-seven such bungalows 
 for the isolation of one or more patients. A patient here is not 
 only isolated from his friends, which is usually a distinct advan- 
 tage, but is isolated from the insane, which is an even greater 
 gain. I cannot take time to describe it here, but it shares with 
 Iwakura in Japan the distinction of being an ideal retreat from 
 the standpoint of environment and construction for mental cases. 
 
 We find then in Japan and in France a certain standard 
 already attained and realized, which we might take for our own. 
 These two places leave nothing to be desired in the way of 
 surroundings and method of construction. We should perhaps 
 be able to add something of our modern machinery to these 
 plans, in the way of central heating, organization of food supply 
 and service, telephonic intercommunication, and latter day hydro- 
 therapy, but these are not the essentials. The essentials for the 
 care of the curable insane are already here, and these are ade- 
 quate nursing, segregation, the return to nature, the simple life,
 
 8 THE INSANE IN JAPAN 
 
 beautiful surroundings, association with normal and not insane 
 persons, and plenty of space and opportunity for walks, for 
 working in gardens and fields and at various arts and crafts. 
 
 Have we already drifted too far from the realization of Vanves 
 and Iwakura, with our vast aggregations of 3,000 to 5,000 patients 
 in one institution, with the sinking of the individual in the mass, 
 with our appalling overcrowding, with our inferior nursing staff 
 and insufficient medical staff, with our at best rudimentary 
 methods of occupation, and with our immense, expensive and 
 complicated machinery of mere support and custody?
 
 A STUDY IN RACE PSYCHOPATHOLOGY 
 By George H. Kirby, M.D, 
 
 DIRECTOR OF CLINICAL PSYCHIATRY, MANHATTAN STATE HOSPITAL, 
 
 ward's island, N. Y. 
 
 Studies in psychopathology which seek to analyze and compare 
 the abnormal mental states found in the different branches of the 
 human race touch a number of highly interesting topics and have 
 an important bearing, not only on the special problems of psy- 
 chiatry and mental hygiene, but they also promise to furnish 
 valuable data for educators and social workers. 
 
 Just as we see racial traits and peculiarities of a people finding 
 expression in their normal mental activities, in their religion, 
 morals, politics and artistic productions, so we may expect to dis- 
 cover that racial characteristics are imparted to the abnormal 
 mental life, modifying or coloring the clinical forms of those psy- 
 choses common to the different ethnological groups of mankind.^ 
 But our inquiry leads us further than the study of how the form 
 and symptoms of a psychosis may vary in different races ; the 
 deeper and more important question of etiology becomes the prin- 
 cipal consideration when it is shown that one race is more liable 
 than another to suffer from a certain kind of mental disease. The 
 cause for this susceptibility of one race and relative immunity of 
 another can only be explained fully when a whole series of com- 
 plex factors has been analyzed. 
 
 In the large group of mental disorders dependent on exogenous 
 causes, such as syphilis, alcohol, infectious diseases or other phys- 
 ical disturbances, we see clearly the important role played in the 
 genesis of these psychoses by the sexual life, social customs, occu- 
 pations and habits of the race. 
 
 In the other large group of mental disorders, the so-called func- 
 tional psychoses, endogenous etiological factors seem to play the 
 
 * See an interesting report by Professor Kraepelin on the Mental Dis- 
 orders of the Natives of the Island of Java. Centralblatt fur Nerven- 
 heilkunde und Psychiatric, Vol. 15, 1904, p. 433. 
 
 9
 
 lO A STUDY IN RACE PSYCHOPATHOLOGY 
 
 most important role and among these are to be mentioned in the 
 first place certain general tendencies of the personality, analysis 
 of which allows us to differentiate several types of mental makeup. 
 My interest in this investigation was first awakened by Meyer's 
 description of the various types of personality and constitution, 
 and their meaning for psychiatry.^ Interest was further stimu- 
 lated by Hoch's recent communication on types of mental makeup 
 and their relation to the functional psychoses. In the light of 
 these studies the subject of race psychopathology becomes espe- 
 cially important. If groups of individuals, because of a peculiar 
 kind of mental makeup, are prone to develop a certain form of 
 psychosis, then in the larger racial divisions which present such 
 distinctive types of character and personality, we may also expect 
 to find that certain forms of mental disturbance predominate in 
 the one or the other race. To understand this racial tendency 
 through analysis of the factors operative in the inner mental life 
 of a people would mean to make an important addition to our 
 knowledge of the development of the functional psychoses. 
 
 Most of the studies hitherto made in comparative psychiatry 
 are of little value. This is the natural result of the lack of uni- 
 formity in the clinical conceptions of different observers, together 
 with the confusion in nomenclature. It is, therefore, to-day 
 utterly useless to attempt to use the hospital reports of different 
 countries in order to estimate the frequency with which any par- 
 ticular mental disorder occurs in the various races, or to learn 
 what deviations, if any, exist in the clinical forms of the psychoses 
 occurring among the different peoples of the world. For investi- 
 gations in this field to be of any value, it would seem essential, as 
 pointed out by Kraepelin, that the studies be carried out by the 
 one observer ; otherwise, no comparable data are to be expected. 
 This requirement is readily met at the Manhattan State Hospital 
 where the clinical material offers a rare opportunity for research 
 in comparative psychiatry. In New York city the conditions of 
 a nice experiment are practically fulfilled in that a number of 
 races of pure blood are found living in large colonies in a uniform 
 general environment. The outcome of such a situation must be 
 full of interest to the psychopathologist. 
 
 'An Attempt at Analysis of the Neurotic Constitution. Adolf Meyer, 
 American Journal of Psychology, Vol. XIV, p. 90, July-September, 1903.
 
 A STUDY IN RACE PSYCHOPATHOLOGY 
 
 II 
 
 In this preliminary report I wish to present merely the result 
 of a review of the clinical material of the past year^ made to 
 ascertain the relative frequency of the different psychoses in the 
 various races entering the hospital. Among the admissions during 
 the year were found representatives of twenty-seven different 
 racial groups. In seven of these groups the number of cases 
 seems sufficiently large to allow certain comparisons. Our attempt 
 has been made to compare in the first place racial stocks, without 
 regard to nationality or geographical distribution. Under the 
 Irish, for instance, we include native-born Irish and the first 
 generation of children born in America of native Irish parents. 
 In a similar way the German, Italian and English groups are 
 formed. We have restricted the American group so as to com- 
 prise only those indivdiuals whose parents were born in the United 
 States, but this does not include the Negroes and Jews, who are 
 kept apart and form each a group without regard to country of 
 birth or length of time in America. 
 
 Psychosis. 
 
 Psychoses with organic nervous 
 disease , 
 
 Senile psychoses 
 
 General paralyses , 
 
 Alcohol ic psychoses 
 
 Infective-exhaustive 
 
 Involution melancholia 
 
 Depressions undifferentiated 
 
 Dementia praecox 
 
 Paranoic conditions 
 
 Manic-depressive 
 
 Epileptic psychoses 
 
 Constitutional inferiority and 
 psycho-neuroses 
 
 Idiocy and imbecility 
 
 Unclassified 
 
 Total number persons each race 
 
 
 . 
 
 . c 
 
 js a 
 
 ja V 
 
 ui U 
 
 .2 
 
 ■?u 
 
 
 
 2.69 
 
 0.98 
 
 9.80 
 
 2.87 
 
 7..S9 
 
 14.05 
 
 27.69 
 
 0.32 
 
 5.39 
 
 4.47 
 
 1.71 
 
 3.19 
 
 1.96 
 
 5. 43 
 
 I3.4« 
 
 27.47 
 
 S-M 
 
 I.S9 
 
 16.66 
 
 28.43 
 
 2.20 
 
 1.59 
 
 2.94 
 
 6.07 
 
 0.24 
 
 0.98 
 
 2-45 
 
 2.5s 
 
 408 
 
 313 
 
 su 
 
 I-" V 
 
 1-54 
 6.70 
 20.10 
 11.85 
 8.64 
 2.06 
 
 5.15 
 14.95 
 
 8.25 
 12.89 
 
 4.64 
 
 4.64 
 
 0.51 
 2.06 
 
 194 
 
 2.38 
 
 7.14 
 
 17.46 
 
 11.90 
 
 4.76 
 
 1.58 
 
 1.58 
 
 16.66 
 
 7.92 
 18.25 
 
 3.17 
 
 3.96 
 0.79 
 2.38 
 
 126 
 
 
 
 
 1h ^ 
 
 
 
 p:s 
 
 -a c 
 
 •5 S S 
 
 = U 
 
 boCJ 
 
 T.*-^ 
 
 OS^ 
 
 2 I- 
 
 
 
 = (3b 
 
 
 1.96 
 
 2.85 
 
 1.53 
 
 3.70 
 
 9.80 
 
 5-71 
 
 5.64 
 
 9.87 
 
 29.41 
 
 14.28 
 
 10.25 
 
 8.64 
 
 7.82 
 
 11.42 
 
 7.69 
 
 8.64 
 
 5.88 
 
 — 
 
 6.66 
 
 1.23 
 
 
 2.8s 
 
 1.53 
 
 8.64 
 
 3.92 
 
 — 
 
 9.22 
 
 23.44 
 
 13.72 
 
 28.57 
 
 29.23 
 
 7.40 
 
 5.88 
 
 8.57 
 
 5.12 
 
 13.58 
 
 9.80 
 
 17.14 
 
 13.33 
 
 4.93 
 
 3.92 
 
 2.85 
 
 1.02 
 
 2.46 
 
 1.96 
 
 5-71 
 
 2.56 
 
 1.23 
 
 — 
 
 — 
 
 — 
 
 6.17 
 
 5.88 
 
 — 
 
 6.15 
 
 81 
 
 51 
 
 35 
 
 195 
 
 
 
 25 
 
 92 
 
 184 
 
 182 
 
 74 
 28 
 
 64 
 284 
 
 74 
 
 253 
 
 36 
 
 53 
 
 7 
 
 45 
 
 1403 
 
 The accompanying table shows the results of the analysis. The 
 total number of patients included in the study was 1,403. The 
 bottom row of figures shows the number of each racial type 
 admitted to the hospital, the Irish with 408 persons forming the 
 
 ■ Cases admitted from October i, 1907, to September 30, 1908.
 
 12 A STUDY IN RACE PSYCHOPATHOLOGY 
 
 largest group, the English with 35 persons forming the smallest. 
 The vertical columns show the percentage distribution of the vari- 
 ous psychoses within each racial group. 
 
 Irish stock furnished nearly 30 per cent, of all the admissions. 
 The figures for this race demonstrate in a most convincing manner 
 the important role played by alcohol in the mental disturbances of 
 the Irish people. Twenty-seven per cent, of all the Irish admitted 
 were suffering from alcoholic insanity, the proportion being more 
 than double that found in any other race. Within the alcoholic 
 group itself the Irish contributed 62 per cent, of all the cases (113 
 out of 182 cases of alcoholic insanity). Accompanying this extra- 
 ordinarily large percentage of alcoholic disorders we find further 
 that the Irish stand highest in senile dementia and psychoses 
 accompanying organic nervous diseases. In general paralysis, on 
 the other hand, the percentage is lower than in any other race. 
 This latter finding was rather a surprise. It is an interesting fact 
 taken in connection with the view often expressed, that alcohol 
 plays an important role in conjunction with syphilis in the causa- 
 tion of general paralysis. Our figures for the Irish race tend to 
 show a closer relationship between alcoholism, senile dementia 
 and various organic brain diseases than between alcoholism and 
 the meta-syphilitic disorders, such as general paralysis. 
 
 The figures for the Jewish race bring out several interesting 
 facts. One notices first of all that the Hebrews are practically 
 free from alcoholic psychoses. The figure .32 per cent, represents 
 a single case which occurred in a series of 182 cases of alcoholic 
 insanity. I must also add that this particular patient, a man, is 
 still under observation, having been over a year in the hospital 
 and certain features in the development of the psychosis as well 
 as the course of the disorder suggest the possibility that the case 
 may after all belong with the paranoid dementias. We notice the 
 further interesting fact that the absence of alcoholic insanity in 
 the Hebrew is accompanied by the lowest figure for senile 
 dementia and psychoses with organic nervous diseases. The next 
 most noteworthy fact gathered from the second column is that the 
 Hebrew race shows by far the greatest percent-age of manic- 
 depressive cases (28.43 per cent.) and the Jew also stands highest 
 in the psycho-neuroses and constitutional inferiorities and in invo- 
 lution melancholia. In dementia prsecox, with the exception of
 
 A STUDY IN RACE PSYCHOPATHOLOGY I 3 
 
 the English people (28.57 P^r cent.), the Hebrews are again fore- 
 most (27.47 per cent.). In the undifferentiated depressions they 
 are next to the highest. We thus see that in the large group of 
 the so-called functional psychoses, by which we mean those dis- 
 orders in which certain endogenous or psycho-genetic factors seem 
 most important as upsetting causes, the Jewish people outnumber 
 enormously any other race. 
 
 Among the Germans general paralysis ranks high (20.10 per 
 cent.), a higher percentage being reached only in the Negro (29.41 
 percent.). Mental disturbances of alcoholic origin are also rather 
 frequent in the Germans, and one observes a striking uniformity 
 in the figure for the Anglo-Germanic group — the German, Amer- 
 ican and English groups each showing 11 per cent, of alcoholic 
 psychoses. We notice further that the Germans are also rela- 
 tively high in senile psychoses, infective-exhaustive states, para- 
 noic conditions, and the psycho-neuroses and constitutional infe- 
 riorities. In the manic-depressive group the Germans rank low 
 (12.89 P^r cent.), the only lower figure being found among the 
 Negroes (9.80 per cent.). 
 
 The figures for descendants of native born Americans are given 
 in the fourth column. The percentages in this group seem to 
 occupy somewhat of an intermediate position between those of the 
 other races, that is to say there are no extraordinarily high or any 
 strikingly low figures in the American group. Manic-depressive 
 insanity is, however, rather high, a higher percentage being found 
 only in the Hebrew ; in alcoholic psychoses and general paralysis 
 a relatively high figure is reached by the native Americans. 
 
 In the remaining three races — Italian, Negro and English — the 
 number of cases is smaller than in the preceding groups and the 
 percentages are therefore probably less representative for these 
 races. 
 
 In the Italian group we find that general paralysis and alcoholic 
 psychosis are both strikingly low. The undifferentiated depres- 
 sions and dementia prsecox are high. Epileptic disorders are more 
 frequent than in any other race {4.93 per cent.). We see further 
 that the unclassified group shows a high figure which may mean 
 that the Italian people offer a larger number of atypical or obscure 
 disorders than other races. It may be, however, that inaccessi-
 
 14 A STUDY IN RACE PSYCHOPATHOLOGY 
 
 bility because of the language difficulty is partly responsible for 
 this high figure. 
 
 In the black race we meet with a remarkably high percentage of 
 general paralysis (29.41 per cent.), higher by far than that found 
 in any other race. This figure may surprise one in view of claims 
 not long since made that the Negroes were almost entirely free 
 from meta-syphilitic disorders, not only general paralysis but also 
 tabes. The proportion of women among the Negro general para- 
 lytics seems to be unusually high. The average of all races exclu- 
 sive of the Negro was not quite 4 men to i woman. In the 
 Negroes we find the proportion to be 3 men to 2 women. The 
 alcoholic disorders are lower in the Negro than in any other race 
 except the Hebrew. This low proportion of alcoholic insanity 
 was hardly expected, as the Negro has been described as being 
 especially sensitive to toxic influences. Manic-depressive insanity 
 seems to be infrequent in the Negro, the percentage (9.80) being 
 in fact lower than that found in any other race. 
 
 Among the English patients, of whom there were only a small 
 number admitted, 35 altogether, we find that dementia praecox 
 is proportionately more frequent than in any other race (28.57 V^^ 
 cent.), the figure being, however, only slightly higher than that 
 found in the Hebrew (27.47 per cent.). 
 
 The more important results of the study may he summarized 
 as follows: 
 
 The Irish are clearly more prone to develop alcoholic disorders 
 than any other one of the races considered. They are also more 
 liable to senile deterioration and other psychoses with organic 
 brain disease. 
 
 The Jewish race seems practically free from alcoholic insanity. 
 The Hebrew, however, ranks higher by far than any other race 
 in the functional group of psychoses made up of manic-depressive 
 insanity, dementia praecox, constitutional disorders and depres- 
 sions of various form. 
 
 In the Negro general paralysis occurs proportionately with 
 more frequency than in any other race. Alcoholic disorders re- 
 main at a low figure. In the functional psychoses, particularly 
 manic-depressive, the Negro ranks low. 
 
 The Germans are relatively high in general paralysis. 
 
 The Italians are low in both general paralysis and alcoholic
 
 A STUDY IN RACE PSYCHOPATHOLOGY 1 5 
 
 insanity. They are highest in epileptic disorders and furnish the 
 largest percentage of unclassified cases. 
 
 The English are highest in dementia prsecox but the small num- 
 ber of English people included in the study renders this figure 
 rather unreliable. 
 
 The American group shows no striking figures when compared 
 with other races, but manic-depressive insanity, general paralysis 
 and alcoholic disorders reach a relatively high percentage in people 
 whose parents were born in the United States.
 
 THE CURABILITY OF EARLY PARESIS 
 
 By Charles L. Dana 
 
 professor of nervous diseases, cornell university medical college, n. y. 
 
 Introductory 
 
 In Professor Tanzi's recent work on Mental Diseases, discuss- 
 ing progressive paralysis, he states that the disease may be unrec- 
 ognized for years and that the actual duration of paresis may be 
 ten or fifteen years — in fact may last as long as do cases of tabes. 
 
 With regard to the prognosis, he says : 
 
 "Although it is dogmatically stated that progressive paralysis 
 is essentially an incurable and fatal disease, we can not entirely 
 exclude that if it is promptly diagnosed and energetically treated, 
 the morbid process may be arrested. Moreover, the essentially 
 initial lesions of progressive paralysis (chromatolysis of nerve 
 cells, tumefaction of cell body) are not of a destructive character, 
 nor are they altogether irreparable" (Tanzi, Mental Diseases, 
 1909, p. 419). 
 
 Dr. Gilbert Ballet recently reported a case (Societe de Psychia- 
 trie, L'Encephale, February 10, 191 1) of a patient who in 1902 
 or 1903 presented very marked delusions of grandeur with symp- 
 toms of tabes. The patient recovered from his mental disturb- 
 ance and is now well. Ballet considered him to belong to a group 
 of cases to which he has called attention, of general paralysis with 
 possible arrested evolution, " paralysis generale a evolution dis- 
 continue." 
 
 These are practically the views for which I have contended in 
 the papers, the first being published seven years ago : viz. that 
 so-called luetic neurasthenia, luetic melancholia and luetic pseudo- 
 paresis are often if not always, preliminary and preparatory stages 
 of paresis. If energetically treated, the patient is cured or re- 
 lieved, if not treated, the malady usually goes on into the degen- 
 erative and incurable stage. It occasionally happens that a 
 
 3 17
 
 1 8 THE CURABILITY OF EARLY PARESIS 
 
 periodic functional psychosis (mania or melancholia) may be 
 grafted upon a nervous lues. 
 
 The view that cerebral lues is one disease and paresis quite 
 another is too narrow a one to hold in the light of recent observa- 
 tions. 
 
 In an inflammatory process we do not call the initial con- 
 gestion and exudation one disease, the terminal cell degeneration 
 and necrosis another, though one is curable, the other is not. So 
 it seems to me that a cerebral lues with neurasthenic and mild 
 paretic symptoms represent the beginning yet curable phase of a 
 process that naturally and untreated ends in a hopeless degen- 
 eration. 
 
 Some interesting facts regarding the essential unity of the 
 processes have been furnished by the newer methods of studying 
 the blood and cerebrospinal fluids. 
 
 So far, the laboratory observations have not furnished any sure 
 criterion by which we can say that a case is nervous lues, or is 
 paresis. In each condition, there is an increase of cells in the 
 cerebrospinal fluid, though less in paresis than in exudative syph- 
 ilis of the brain ; in each the blood and cerebrospinal Wassermann 
 tests and the globulin tests are positive, — more intensely so in 
 paresis, as a rule. 
 
 Dr. Kaplan has shown that under mercurial treatment the reac- 
 tions of the cerebrospinal fluid in tabes, paresis and cerebrospinal 
 lues respond in the same way. In all three of these conditions 
 there are found before treatment : 
 
 Lymphocytosis 4- 
 Globulin test -}- 
 Blood-Wassermann + 
 Cerebrospinal Wassermann + 
 Fehling's reaction o 
 
 Under treatment, there comes usually earliest a reduction in the 
 number of cells ; then the globulin reaction becomes negative, then 
 the blood-Wassermann and finally the cerebrospinal Wassermann 
 tests also become negative. As the lymphocytosis diminishes the 
 Fehling reaction returns. These reactions suggest that we are 
 attacking the same conditions ; and not as I believe three different 
 diseases.
 
 THE CURABILITY OF EARLY PARESIS 1 9 
 
 So far as investigations yet have gone, then, it seems rather 
 plain that paresis is not a disease sharply split off from cerebral 
 lues but rather a later phase of it. The exact line can not yet 
 be drawn, but I contend that there is often a long period of time 
 during which symptoms occur that are " pre-paretic," and that 
 this condition should be recognized since it is curable, in the sense 
 that it is kept as permanently under control as lues itself can 
 be kept. 
 
 The phases in which pre-paresis shows itself most commonly 
 are: (i) Luetic neurasthenia, (2) luetic neurasthenia with paretic 
 symptoms (pseudo-paresis) (meningeal and cortical lues), (3) 
 luetic melancholia and mania. 
 
 The forms of cerebral and spinal lues with local exudates, gum- 
 mata, etc., may or may not be associated with or become pre- 
 cursors of paresis. 
 
 My experience teaches me that spinal exudative syphilis (in 
 the common form of Erb's paralysis) is rarely followed by 
 cerebral but often by spinal degenerations; cerebral syphilis with 
 exudates are not ominous if they involve the brain stem; but 
 the diffuse meningeal lues involving probably the cerebral cor- 
 tex causes symptoms resembling paresis and leads directly to 
 it unless treated. In this condition the symptoms sometimes can 
 not be distinguished from the symptoms of paresis; and if neg- 
 lected the evidences of degeneration in time almost invariably 
 appear. 
 
 FIRST PAPER, READ NOVEMBER, I904 
 
 I wish to present what to my mind is convincing evidence that 
 paresis, in its very earliest stages, in that stage which may be 
 called one of " preparesis," is a disease that sometimes can be 
 arrested. This arrest may be permanent, and may be attended 
 with so little mental defect that one may call the patient practi- 
 cally cured. 
 
 Paresis, Tabes and Syphilis. — It is now quite generally admitted 
 that paresis is almost always a parasyphilitic disease ; that is to say, 
 one which is due to the late and degenerative influence of a luetic 
 poison. Paresis is also looked on as a disease which has the same 
 relation to the brain structures that tabes dorsalis has to those of 
 the spinal cord.
 
 20 THE CURABILITY OF EARLY PARESIS 
 
 This relationship, indeed, is so often and so plainly observed 
 that it can be considered a proved clinical and pathologic fact. 
 We find for example, in from 5 to 10 per cent, of the cases of 
 degenerative syphilis of the nervous centers that the patient 
 suffers both from paresis and from tabes, and has what is termed 
 " tabo-paresis," the paresis gradually associating itself with tabes, 
 or vice versa. 
 
 The Arrest of Tabes. — Now, nothing is more clearly established 
 than the fact that tabes dorsalis is often arrested in its early 
 stages, so that a patient may live for ten, twenty or thirty years, 
 and exhibit no practical progress or change in his symptoms. I 
 have a number of patients under observation who illustrate this 
 undoubted condition; and my experience, I am assured, is the 
 common one. 
 
 If, then, tabes may be arrested in its early or pretabetic stage, 
 there seems no reason to suppose that we can not also arrest and 
 cure paresis in its earlier stage, and this is what I believe can 
 be done. 
 
 The cases which I report, taken in connection with other clinical 
 experiences which it is impossible to present without making my 
 paper too long, have been sufficient to make me feel quite sure of 
 my position in the matter. I am not asserting that paresis, when 
 it is once well established, can be cured. In fact, I do not think 
 it can be ; and I know of no more hopeless malady when it has 
 once got a full start. 
 
 Paresis not infrequently shows remissions, and these remissions 
 may be prolonged to one or two, or even to five or six years. In 
 these remissions, however, the mind, by no means, is restored to 
 its original tone or vigor. The patient has only a "let-up," and 
 is never the sound, vigorous-minded man he was previously. My 
 patients have been more than cases of remission ; their condition 
 of mind and body has been restored, practically, to a normal level. 
 I am not asserting the existence of remissions in paresis ; that is 
 one of the admitted features in the natural history of the disease. 
 What I do assert is that in some cases in which the patient has 
 shown unmistakable evidences of a degenerative and paretic 
 process starting in the brain, this process has been arrested, evi- 
 dences of it have even sometimes entirely disappeared, and the 
 patient has gone on with his usual work.
 
 THE CURABILITY OF EARLY PARESIS 21 
 
 I have not yet had patients under observation for a sufficiently 
 long period of years to enable me to say that the paresis will never 
 return. I can only argue from analogy in the cases of tabes dor- 
 salis, and since we know that here the arrest of progress is some- 
 times permanent, we may legitimately infer that when it has 
 occurred in paresis in the same way it may also be permanent. 
 I would say, further, that there is nothing a priori impossible in 
 the idea that paresis may be arrested and cured when it first starts 
 in. We are able to arrest degenerative processes in other parts 
 of the nervous system; we arrest degenerative processes, or we 
 see them arrested, in the kidneys, in the liver and in other organs. 
 Given a vigorous constitution poisoned with disease, it may well 
 be that when it is put under the best possible conditions for fight- 
 ing this poison, when its known antidote has been administered 
 with heroic thoroughness, we might expect that the tendency of 
 the tissue to die may cease. 
 
 Pseudoparesis. — Also, in speaking of paresis, I wish to be 
 understood that I am speaking only of general paresis or paralytic 
 dementia, not of the so-called " pseudoparesis " of alcoholics or 
 the "pseudoparesis" of syphilis. I have used these terms per- 
 sonally, and I know they are widely adopted as convenient expres- 
 sions. I do not think, however, that this term, " pseudoparesis " 
 is a very fortunate one, inasmuch as the disorders above men- 
 tioned are essentially simple forms of organic dementia, with an 
 entirely different pathologic basis and clinical course from the real 
 paresis. The so-called pseudoparesis of alcoholism, for example, 
 is only an organic dementia, due to the connective tissue prolifera- 
 tion, the vascular changes, and the cellular atrophy brought on 
 by the continued use of alcohol. The pseudoparesis of syphilis is 
 simply a dementia brought on by the exudates of syphilis, leading 
 to more or less severe secondary changes in the meninges and in 
 the vascular supply. It is really an organic dementia, due to an 
 exudative inflammation of the meninges and blood vessels. In 
 true paresis the organic changes are comparatively slight at the 
 beginning, and are probably mostly of a parenchymatous nature. 
 There is no exudate and no early gross organic change. It is 
 true, however, that in the early stages of paresis there may be 
 some slight amount of luetic exudate, and that perhaps the degen- 
 erative changes in the cell are started by this process. We know
 
 22 THE CURABILITY OF EARLY PARESIS 
 
 also that there are cases of paresis in which there are both true 
 primary degenerative changes and real syphilitic exudates present 
 at the same time, so that the patient may be said to be suffering 
 both from brain syphilis and from a paresis. It is strictly analo- 
 gous to the conditions which occur in a spinal cord, where at 
 times there may be a true tabetic degeneration and at the same 
 time a decided syphilitic exudate, so that we have both locomotor 
 ataxia and spinal syphilis together. 
 
 It is at this point that the weakness of my case, as I freely 
 admit, may lie. It may be and probably will be contended that 
 the cases which I assert are in the stage of " preparesis " are really 
 cases only of slight exudative brain syphilis, and that my patients 
 have simply been cured of a slight degree of a perhaps rather 
 diffuse vascular and meningitic exudate. To this I can only 
 reply that I have many times seen precisely this class of cases 
 passing directly into a condition of true paresis, and that in all 
 of my cases where there were admittedly some symptoms of 
 syphilitic exudate, or some kind of gross organic lesion, there 
 were with it also decided psychical and somatic symptoms, such 
 as occur only, or mainly, in connection with the degenerative 
 process of paresis. An Argyll-Robertson pupil, for example, is 
 the sign of the onset of a degeneration, not of exudation. At the 
 very most, while admitting that my opponents may be academic- 
 ally right, I would claim that they are practically wrong, for the 
 reason that, basing my argument on experience with other cases, 
 I feel sure that all or nearly all of these patients would have gone 
 into a condition of true paresis if they had been let alone. Thus, 
 when a patient who has given a distinct history of syphilis develops 
 a form of agitated melancholia, and at the same time shows signs 
 of cerebral degeneration, like the Argyll-Robertson pupil and dis- 
 turbances in the knee reflexes, I should certainly be apprehensive 
 that, under ordinary conditions, he would eventually develop a 
 paresis, for I have seen a number of patients who entered paresis 
 through this peculiar gate of melancholia, with somatic signs as 
 indicated. 
 
 Again, if a patient with a history of syphilis, after a certain 
 period begins to develop convulsions and shows Argyll-Robertson 
 pupils, exaggerated reflexes, then begins to develop symptoms of 
 loss of memory, change of character and disturbances of the
 
 THE CURABILITY OF EARLY PARESIS 23 
 
 instinctive feelings ; I should feel very certain that if left alone 
 he would pass into the condition of paresis, for it is through the 
 gate of convulsivedisturbances, epileptiform seizures and peculiar 
 somatic signs that paresis sometimes develops. 
 
 Still further, when a patient, who gives perhaps a doubtful his- 
 tory of syphilis but whose life is such that he might easily have 
 been subjected to it, and who has a headache, an eye-palsy, and 
 previous to that has for some time shown great extravagance in 
 action and ideas, with a decided change in character and weakness 
 of memory, I would here also feel very sure that a paresis was 
 developing. 
 
 Having observed the total disappearance of all these symptoms, 
 under treatment, and the restoration of the patients practically to 
 their former health, it has seemed to me that I may be right in 
 claiming that it is possible to arrest for an indefinite time a dis- 
 ease which is certain to become a general paresis. 
 
 With these preliminary remarks, I submit the following rec- 
 ords. They are not published in every detail because it seemed 
 to me not necessary. I have given the salient facts with regard 
 to the symptoms and course ; besides this, the patients were all 
 private patients of my own or of physicians who referred the 
 cases to me, and some of the patients were men of prominence, 
 whose intimate lives and identity I should dislike to expose. The 
 histories should perhaps carry greater weight for the reason that 
 they are not records of hospital or dispensary cases, in which 
 data are often uncertain and the mental development of the pa- 
 tients of mediocre type: 
 
 Case Reports 
 
 Case i. — M. S., aged 40, married; occupation, broker. 
 
 History. — Family history shows a very bad indirect heredity. The 
 patient had an infection before he was 20, which was treated. He had 
 had seven healthy children. He had led a life of much social activity and 
 business excitement. Three months before I saw him he began to get 
 ideas of poverty and self-reproach, and when I saw him he had a distinct 
 melancholia. 
 
 Examination. — The pupils were unequal, the left larger than the right; 
 both distinctly Argyll-Robertson in type, though the right reacted very 
 feebly to light. He claimed, however, that the left pupil had been larger 
 than the right for fourteen years, and that this condition was due to a 
 sunstroke (?). The left knee jerk was lively, the right weak. He had
 
 24 THE CURABILITY OF EARLY PARESIS 
 
 some tremor of the hands, but none of the face. There was no speech 
 disturbance. He had had no seizures. Mentally he showed no dementia, 
 but only a very profound and anxious depression, with some delusions 
 of poverty and self-accusation. He suffered from insomnia, but had no 
 headaches, and had no cranial nerve palsies except those of the eyes, and 
 no disorders of the spinal centers or ataxia. 
 
 Treatment and Result. — He was seen by two physicians, one a very 
 competent neurologist, who thought that he was developing paresis. He 
 was sent to a sanitarium, where he was put under active treatment. In six 
 months he came back practically well. The pupil of the right eye had 
 become normal; the left was the same as before; knee jerks same as 
 before. He has continuted well and has been in active business now for 
 over three years. 
 
 Case 2. — J. D. H., aged 37, married ; merchant by occupation. 
 
 Family History. — Direct heredity good; one sister had epilepsy; no 
 other neuroses in the family. 
 
 Personal History. — He had a luetic infection twelve years ago. He 
 was a man of temperate habits, but worked extremely hard. About two 
 years before I saw him he began to run down and complained of sensa- 
 tions of pressure on the side of his head, which symptoms continued very 
 persistently. 
 
 Examination. — The pains and paresthesias extended down the back of 
 the neck and into the shoulders. In other words, he had the annoying 
 head, neck and shoulder paresthesias seen in beginning paresis. As his 
 condition grew worse he began to be drowsy, and apparently required more 
 sleep than normal. Three weeks before I saw him he had had two con- 
 vulsions of an epileptiform character. At that time he was emotional and 
 depressed, crying easily, and having apprehensions about his mind giving 
 way. When seen by me he had been taking for some days 15 grains of 
 bromid in the morning and 6 grains of trional at night. At this time 
 he was depressed, his memory was poor, his spech was syllabic, but he 
 had no tremor, and the pupils were normal, as were also the knee jerks. 
 He was then having attacks of excitement at intervals with, at times, some 
 brief delusions, but no hallucinations. He complained of his head and 
 was very depressed and apprehensive. He appeared to me to have the 
 physiognomy of a patient likely to develop paresis, and the history of 
 convulsions, his speech disturbance, his feeble memory and his melan- 
 cholia, all pointed in that direction. At the time I made a diagnosis of 
 paresis, with a question mark. 
 
 Treatment and Result. — The patient was sent to the Watkins sani- 
 tarium, where he remained for several months under the care of Dr. King. 
 He had one more convulsion. He returned much improved and gradu- 
 ally recovered. He has continued well to the present time, which is four 
 years from the period when I first say him. 
 
 Case 3. — B. R., aged 34, married; occupation, business. Family history 
 negative.
 
 THE CURABILITY OF EARLY PARESIS 25 
 
 History. — He has smoked a great deal. At i8 he had a luetic infection 
 and " secondaries," and was treated for two years. Since that time he 
 has had occasional periods of depression. In the two months before 
 his visit to me he had again become very much depressed and melancholy. 
 
 Examination. — When seen by me he had no objective symptoms of any 
 form of nervous syphilis. A week or two later he complained that at 
 times he had shooting pains in the legs, the right pupil was then larger 
 than the left, but the pupils both reacted to light and to accommodation. 
 The reflexes were present, and he had no ataxia. 
 
 Subsequent History. — I lost sight of him then, but saw him again six 
 months later. He then complained that his memory was poor, and that 
 he was unable to concentrate his mind at business. He felt generally 
 weak. His speech was not perfectly good, his articulation being some- 
 what thick at times, and he now had a distinct facial tremor and Argyll- 
 Robertson pupils. His symptoms in general were those of forgetfulness, 
 inability to concentrate the mind, occasional headache, and depression at 
 times, though this had improved of late. This, it seemed to me, was 
 sufficient to justify a diagnosis of probable paresis, and what I at first 
 considered to be merely a mild attack of melancholia seemed now to be 
 probably a very serious condition. 
 
 Treatment. — He was placed on mercury and tonics and sent ofif to 
 rest. He steadily improved, and at the present time, now three and a half 
 years since I last saw him, he is perfectly well and has been attending to 
 his work for the last three years. 
 
 Remarks. — This might, perhaps, be interpreted as a case of recurrent 
 melancholia with cerebral syphilis, but I think that, at least, with the 
 speech disturbances, Argyll-Robertson pupil and facial tremor in mind, 
 we may assume that a paresis would naturally have developed. 
 
 Case 4. — J. R. K., aged 30; lawyer. 
 
 History. — He had an infection ten years before and was thoroughly 
 treated for four years ; he had had " secondaries," and during the last 
 three years had had throat trouble, but not of a specific character. His 
 habits are good, except that he has been a very hard worker. Two years 
 before I saw him he began to have a slight amount of ataxia, and at the 
 same time had some deafness. Six months ago the ataxia was very much 
 better. One month ago he had pain in the eyes and diplopia, due to a 
 paresis of the right externus. 
 
 Examination. — The fundus was normal. He had Argyll-Robertson 
 pupils. He had great exaggeration of the patellar reflexes, no ankle 
 clonus nor Babinski sign, some ataxia oti standing and locomotion; 
 mentally he was very nervous and excitable; he was unable to concen- 
 trate his mind and had some impairment of memory. 
 
 Remarks. — The diagnosis was made of impending tabo-paresis. This 
 was two years ago. Since then he has been steadily improving and be- 
 came able to resume work. He has now been attending to his work as a 
 lawyer regularly for nearly two years, and though still ataxic and not by 
 any means well, his mental and physical trouble at least has been im- 
 proved and arrested.
 
 26 THE CURABILITY OF EARLY PARESIS 
 
 Case 5. — S. B., aged 40, married; broker. Family history is good. 
 
 History. — He has always been a very hard-working man; he has 
 smoked immoderately and drank moderately. He had a luetic infection 
 five years ago, with " secondaries," which were thoroughly treated. I 
 saw him first in October, 1903. For nearly a year previous his mental 
 condition had been changing. His wife had noticed that he was more 
 morose, less inclined to social life, often unreasonable, and irritable and 
 forgetful. This was simply attributed to his overwork and to the excite- 
 ment of his occupation. In August, 1903, he had an epileptiform attack 
 during the hours of business. He recovered from this promptly and con- 
 tinued his work. Later, in the month of October, he had another epi- 
 leptiform attack at night, followed by a period of maniacal excitement, 
 lasting for one or two hours, in which he became quite violent. 
 
 Examination. — I saw him the next day. He was a large, robust man, 
 with a very healthy physiognomy. Mentally he seemed practical'y normal, 
 although he was naturally much disturbed and apprehensive over what 
 had occurred. He exhibited to me no traces of forgetfulness or ideas 
 of grandeur. Physically he had distinctly the Argyll-Robertson pupils, and 
 the knee jerks were exaggerated; there was no facial tremor or hand 
 tremor. The writing was normal. He had no lightning pains and no 
 paresthesias. 
 
 Subsequent History. — This patient has now been under observation for 
 over a year. For some time he showed an abnormal exhaustibility and 
 irritability, of both body and mind, so that he tired very easily in walking, 
 and had a disinclination to the mental activity involved in social inter- 
 course. His disposition was for some time a good deal changed ; he 
 was morose, childish and suspicious of his wife, unreasonable and irritable. 
 He, however, never showed any lack of judgment or any forgetfulness in 
 business affairs ; he was only childish in his domestic and in certain social 
 relations. After about six months the pupils, which had been stiff, became 
 normal the knee jerks remained about the same. He had no further con- 
 vulsive seizures. At the present time this patient seems in every way to 
 be a normal man. He had not had any severe headaches, no lightning 
 pains, no disturbance of the spinal centers. 
 
 Remarks. — The probability of an impending paresis was based on the 
 very marked syphilitic infection, which had been rather obstinate in his 
 case, and the occurrence of two convulsions, without previous headaches, 
 the change in his disposition and character, the forgetfulness about things 
 in his domestic relations, a carelessness of speech and manner, which 
 were not natural to him, and the condition of his pupils. His own 
 physician. Dr. Sherwell of Brooklyn, and with whom I had several talks 
 about the case, shared with me, I think, though perhaps to a less degree, 
 the fear that he might develop paresis. This was the club held over his 
 very impetuous nature which obliged him to change entirely his mode 
 of life, and by reason of which I think he escaped the catastrophe. 
 
 Case 6. — H. B., aged 43, married; occupation, broker. Family history 
 unknown.
 
 THE CURABILITY OF EARLY PARESIS 2/ 
 
 History. — The patient, from boyhood, had always been a very hard- 
 working, excitable man. He had lived a pretty fast life, drinking con- 
 siderably, but he was not a smoker. He was a man whose habits of 
 expression and thought were always very extravagant, and whose business 
 dealings had been, normally, of a very large kind. He denied any specific 
 infection, but I am sure he had lived a life which would have exposed 
 him to it. In the spring of 1904 he was under a specially severe strain 
 and had lost a good deal of money. In June he had a paresis of the left 
 internal and right external rectus for which he consulted Dr. Koller, who 
 kindly referred him to me. 
 
 Examination. — When I first saw him in July he talked in a very 
 extravagant and excitable way, telling me remarkable stories about his 
 business, which I believe were more extravagancies than actual delusions, 
 and I learned from his friends that this was his way of talking. He had 
 double vision on account of the internal rectus of the right eye. His 
 pupils were dilated, the left larger than the right, and neither reacted to 
 light, but reacted to accommodation ; the optic nerve and vision were 
 normal. He had a fine tremor of the hands, but none of the face or 
 tongue, and speech seemed clear, though occasionally there was a little 
 slip; his writing also was fairly good. The knee jerks were somewhat 
 exaggerated ; but there was no clonus. He had no ataxia and no light- 
 ning pains. The bladder and sexual functions were normal. The memory 
 did not seem impaired. 
 
 Treatment. — He was given a course of hypodermic injections of 
 mercury, and then went to Europe for six weeks, where he became more 
 depressed. On his return he continued under the treatment of Dr. Koller 
 for his eye condition. He gradually improved, both mentally and physi- 
 cally, until now his eye is nearly normal; he has no tremor, the knee jerks 
 are less exaggerated, and his mental condition is, perhaps, better than 
 it ever was in his life. 
 
 Remarks. — This case might be interpreted as possibly one of paresis, 
 with a remission, but I feel very confident that he did not have a frank 
 attack of paresis when he came to see me, and that he was then suflFering 
 only from a sort of grandiose excitement, with Argyll-Robertson pupils, 
 and an eye palsy. A little further delay and he would have been fairly 
 a paretic. 
 
 Case 7. — This case was less striking than the others, but, taken in 
 connection with them, it has significance. 
 
 Patient. — J. H., aged 46 ; family history good ; designer. 
 
 History. — He had syphilis at the age of 23 and was treated thoroughly 
 by specialists. At 34 he had some mental depression and rheumatic pains. 
 He was relieved by hypodermic treatment with mercurials. He married 
 at 37 and had a healthy child. At 46 he had nervous attacks consisting 
 of agitation and trembling, and he has also had a good deal of dyspepsia. 
 On this was engrafted an "anxious depression" or mild form of hypo- 
 chondriacal melancholia, which did not keep him from work. He had
 
 28 THE CURABILITY OF EARLY PARESIS 
 
 no objective symptoms, but complained of his depression and dyspepsia. 
 He gradually recovered, but a year later complained of entire loss of 
 sexual power, annoying failure to memory, difficulty in concentration and 
 work, and dyspeptic symptoms. This condition continued for a year, 
 with some remissions, but finally he reported himself as practically well 
 of everything but his sexual weakness. He had no symptoms of tabes 
 at any time, except his sexual weakness. I watched constantly for the 
 development of signs of paresis, but he had only the failure of memory, 
 inability to concentrate his mind, and the initial melancholia. 
 
 The patient, from the time he was 34 till he was 46, took courses of 
 mercury by injection. At first he took an injection every two weeks for 
 two years. They acted on him as a tonic, the effect lasting for a week or 
 more. Later he took the injections at much longer intervals. 
 
 These histories, I might repeat, may seem to present inconclu- 
 sive evidence of the real existence of paresis. I think, however, 
 that most of those who are familiar with such cases will admit 
 that they have seen paresis beginning in this way and going on to 
 the full-fledged condition. Such cases certainly have occurred 
 in my experience, and usually after these initial symptoms were 
 already matters of the previous history. 
 
 The importance of recognizing paresis before it is in a way 
 real paresis is the very evident lesson of these histories. 
 
 Treatment. — In conclusion, I would say a word only in regard 
 to the treatment of these conditions. It seems to me that if the 
 cases are recognized early there is no need of any very novel 
 methods of treatment ; there were none employed here. I believe 
 that the patients should at once be turned entirely from their 
 former modes of life ; that they should be sent where they can get 
 rest and fresh air ; that they should receive, if possible, hypo- 
 dermics of the bichlorid or salicylate of mercury, and that this 
 should be accompanied or followed with iodid of potassium and 
 tonic measures. I attach special importance to the effect of hypo- 
 dermic medication, though all the patients did not receive it. It 
 is not always necessary to give large doses, i. e., gr. ^ twice a 
 week is sometimes enough, but this may need to be kept up for 
 two or three months. In other cases gr. ii or even gr. iii once or 
 twice a week are required. The technic requires care. During 
 the course of treatment there should be a very liberal use of luke- 
 warm and hot bathing (a warm bath every day and a hot bath 
 once or more weekly), and every possible attention should be 
 given to the general nutrition of the patient.
 
 THE CURABILITY OF EARLY PARESIS 29 
 
 With these measures I believe that a good proportion of per- 
 sons who are threatened with paresis can be permanently helped, 
 and it is my hope that the medical profession will become trained 
 to recognize these cases so quickly that before many years we may 
 get the same gratifying results in paresis that we do in tabes. 
 
 I have to express my obligations to Dr. Carl Koller, Dr. Alex. 
 Duane,- Dr. Samuel Sherwell, Dr. Jas. R. King, of Watkins, and 
 Dr. Sollace Mitchell, of Jacksonville, Fla., for referring some of 
 the cases to me, for aid in treatment and for furnishing me special 
 notes for the histories. 
 
 SECOND PAPER, READ NOVEMBER 3, I909 
 
 In a paper read before this society five years ago, I made a 
 contention that it was possible to arrest, and probably to arrest 
 permanently, certain cases of paresis when they were observed 
 in the earliest stages and submitted to prompt and prolonged treat- 
 ment. To the objection that the cases cited in illustration of my 
 point were not really cases of paresis, but of cerebral syphilis or 
 " pseudoparesis," I could answer only by contending that there 
 were no possible criteria by which we could distinguish " pseudo- 
 paresis " and certain forms of cerebral syphilis from paresis itself, 
 except by saying that when the patients recovered the cases were 
 false, and when the patients died the cases were real. In the 
 pseudoparetic cases as in true cases, we have headaches, convul- 
 sions, syncopal and aphasic attacks, disturbance of the pupillary 
 reflexes, tremors, cranial nerve palsies, even attacks of hemi- 
 plegia, lymphocytosis of the cerebrospinal fluid, and positive reac- 
 tion to Wassermann's test. In each kind of case also, we find 
 changes in character, increased irritability, inability to conduct 
 business afifairs, defects of attention, somnolence, confusion and 
 quick exhaustibility of the mental processes on exertion. In cases 
 in which paresis is firmly established, with grandiose delusions, 
 real dementia, marked facial and tongue tremors, speech defects, 
 involvement of the pyramidal tracts, I make no claim that the 
 disease can receive, at the most, more than a remission. 
 
 The clinical facts on which my contention is based have been 
 so abundant and positive since I first wrote on this subject that it 
 seemed almost unnecessary to emphasize the point further. I 
 am led to do so, however, because my view has been misunder- 
 stood by some who have jumped to the conclusion that I have
 
 30 THE CURABILITY OF EARLY PARESIS 
 
 asserted that paresis can be cured when fully developed ; also, 
 because my view as to the essential unity of nervous syphilis and 
 parasyphilis has been so strongly confirmed by the discovery of 
 the pale spirochete and the evidence of its activity by Wassermann 
 and other tests in parasyphilitic conditions. 
 
 The observations of Drs. Noguchi and Moore^ show that in 
 general paresis and in cerebral and nervous syphilis, there is a 
 positive reaction both to the butyric acid and the Wassermann 
 test ; also that there is a practically equal evidence of lympho- 
 cytosis in the cerebrospinal fluids. Similar results were obtained 
 by Dr. Rossanoff^ in his observations recently presented before 
 the New York Academy of Medicine. Dr. Kaplan's observations 
 presented at the same time lead to the same conclusions. It is 
 very well established, then, that so far as the blood and the cere- 
 brospinal fluid tests go, there is no qualitative difference in the 
 reactions between paresis and so-called syphilis of the nervous 
 system. There is indeed a rather stronger and more positive 
 reaction in paresis than in the ordinary syphilis of the nervous 
 system.^ 
 
 ^ Noguchi, H., and Moore, J. W. The Butyric Acid Test for Syphilis 
 in the Diagnosis of Metasyphilitic and Other Nervous Disorders, Jour. 
 Exper. Med., July 17, 1909, abstr. in The Journal A. M. A., Aug. 14, 
 1909, LIII, 591. 
 
 ^One of Dr. Rossanoff's conclusions is the following: "Inasmuch as 
 the Wassermann reaction and the butyric acid reactions seem to indicate 
 syphilis only when it exists in an active or potentially active form, 
 their regular occurrence in general paresis would tend to prove that that 
 disease is a manifestation of active syphilis of activity of the Spirochcsta 
 pallida. While the evidence for this view is not as yet complete, it is 
 sufficient to justify its being used as a basis of therapeutic essay." Ros- 
 sanofF also cites a case which was diagnosticated general paresis. The 
 patient, however, recovered under treatment by mercuric injections, where- 
 upon the diagnosis was changed to cerebral syphilis. While it cannot be 
 proved, clinical experience in other cases justifies one in saying that if 
 this patient had not received treatment he would have died with the 
 symptoms of paresis. Cases like this have occurred in my experience and 
 have been potent in forcing me to my conclusions as to the nature and 
 management of this disease. 
 
 'Apelt's later observations (Arch. f. Psychiat., XLVI, No. i) only 
 show that the " Phase I " or globulin reaction does not occur so often 
 in so-called cerebral lues or luetic neurasthenia as it does in tabes and 
 paresis, but it does occur, and all the serum and blood tests indicate only a 
 quantitative, not a qualitative, difference between the conditions.
 
 THE CURABILITY OF EARLY PARESIS 3 I 
 
 The attempt to find a test which should distinguish between 
 paresis and nervous syphiHs or " syphilitic neurasthenia," has 
 been made by Nonne and some of his followers. The most 
 recent observations regarding the utility of what is known as the 
 Phase I Test of Nonne failed to show that it is of any distinct 
 value in distinguishing between these two conditions (Noguchi 
 and Moore^). It follows, then, that since there is an essential 
 underlying unity between true paresis and " luetic neurasthenia," 
 " pseudoparesis," " nervous syphilis," there is no reason to sup- 
 pose that if we can cure one we can not also forestall and even 
 cure the other. This is what I assert to be possible and also, that 
 it is not infrequently done. Over and over again, it has been my 
 experience to see luetic patients suffering in almost the same way, 
 nervously and mentally, and yet, in one case, after a time, a true 
 paresis develops, and in the other case it does not. And, further- 
 more, it has been my experience to see patients who have, clin- 
 ically, developed nearly all the signs of paresis, improved, and 
 remained practically well for years.* 
 
 The ordinary, and perhaps I should say asylum view of prog- 
 nosis of paresis, has been recently presented by Dr. Green,^ who 
 made a very careful study of 200 cases, with reference to this point. 
 He puts the limit of the duration of the disease at five years, this 
 occurring only in the young; and he does not speak even of the 
 possibility of cures, or long remissions. Such a view expresses, 
 I think, a narrow and misleading conception of the malady, for 
 paresis exists sometimes for years before it reaches the alienist 
 or the hospital. A writer in one of the medical weeklies, during 
 
 * Sometimes cases which present mainly the appearance of cerebral 
 syphilis do not improve under treatment, but go on steadily to a fatal 
 termination with all the symptoms of paresis. Two patients came under 
 my care at about the same time, beginning in the same way. One is now 
 apparently in active health ; the other died of paretic dementia. There 
 must, then, be some plus factor in the matter which is potent to bring 
 about the unfavorable result. This may be inadequate or belated treat- 
 ment, or it may be a more degenerate, unstable brain. The luetic poison 
 quickly brings about hopeless toxic changes in ablotrophic cells. Paresis 
 that is fatal, then, is that in which the luetic infection is severe and un- 
 controllable, or that in which the brain-cell, being congenitally weak, easily 
 falls prey to the toxin. This is the only difference which I can see be- 
 tween cerebral syphilis and parasyphilis." 
 
 'Green, Jour. Ment. Sc, 1908 or 1909.
 
 32 THE CURABILITY OF EARLY PARESIS 
 
 the past summer, also states unequivocally that paresis is not only 
 never cured, but surely and always kills, i. e., it is not even perma- 
 nently arrested. This also expresses what I should term a very 
 juvenile view of paresis. Quite appropriately this writer quotes 
 a French novelist in support of his position, but does not, I think, 
 get any appreciation of some more serious writers. As against 
 Guy de Maupassant, I would quote Alzheimer, who states that 
 he has most positive evidence that paresis has remained unpro- 
 gressive for many years. 
 
 I wish now to put on record the final history of the cases which 
 I reported five years ago, as an illustration of arrest in preparetic 
 states. The details of the early history of the cases are given in 
 the article referred to.^ I shall add a few further reports of cases 
 illustrating the clinical fact which I am trying to prove, for I 
 know that it is only by the presentation of such data, accurately 
 and impartially given, that any conviction can be produced; the 
 minds of many alienists, at least, seem to be absolutely fixed in an 
 attitude of pessimism towards the prognosis of paresis in any of 
 its stages. The cases are referred to in the order they were re- 
 ported originally. 
 
 Case i. — A broker, aged 40, had an attack of melancholia, with the 
 somatic symptoms indicating paresis; that diagnosis was made in his 
 case. He had tremors and Argyll-Rohertson pupils, but he had shown no 
 dementia. He improved in the sanitarium and kept well for three years 
 afterward, at which time I reported the case. He continued well for four 
 years more, but he lived a life of great self-indulgence. He had losses 
 in business, and finally developed genuine symptoms of paresis and died 
 in about a year. He had had, therefore, a remission of seven years, 
 during, which he was in every respect a normal man. 
 
 Case 2. — The patient had continued well for four years from the time 
 when I saw him, when his symptoms were marked. He had had a luetic 
 infection twelve years before. His symptoms were those of convulsions, 
 speech disturbance, feeble memory and depression. He has continued 
 well, and is now in active business. It is eight years since he recovered. 
 
 Case 3.— A man, aged 34, had a speech disturbance, Argyll-Robertson 
 pupils, facial tremor and depression to the point of melancholia. When I 
 reported his case he had been attending to his work and was well for 
 the last three years. I saw him again in the past year and he had con- 
 tinued well, so that his remission has thus far lasted eight years. 
 
 Case 4. — A lawyer, aged 30, had all the evidences of a beginning tabo- 
 paresis. The progress of his disease was arrested, and for seven years he 
 has been able to do his professional work with a fair degree of success.
 
 THE CURABILITY OF EARLY PARESIS 33 
 
 Case 5. — A broker, aged 40, had had an infection. His trouble began 
 with a violent epileptic attack, followed by periods of maniacal excite- 
 ment. For a year he had a great deal of mental irritability and de- 
 pression, and a certain degree of weakness of comprehension and judg- 
 ment. He has now continued well for six years since the first attack. 
 
 Case 6. — A man, aged 43, a broker, lost all his money in Wall Street, 
 and then tried to steal some to make good. He developed a melancholia 
 and killed himself. 
 
 Case 7. — This was one of those types of luetic infection, followed by 
 anxious depression or a mild form of hypochondriacal melancholia. For 
 twelve years the patient used to have an injection of mercury, every two 
 weeks. It is now nine years since he was under systematic treatment and 
 he continues well. 
 
 The following further cases illustrate the preparetic state and 
 its possible outcome : 
 
 Case 8.— T. S., aged 46, lawyer, came to me in October, 1906. There 
 was no hereditary history of importance. His father lived to 70, his 
 mother died at 60, of an accident. The patient was married and had 
 three healthy children. He had contracted lues about twenty-three years 
 before coming under my observation. He suffered severely and, though 
 he was treated, his health broke down and he had to rest from business. 
 After his recovery, i. e., for about twenty years, he had been quite well 
 and had seen nothing of doctors until his present illness. About three 
 and one-half years before I first saw him he suffered from sexual weak- 
 ness, which had gradually progressed till he had become practically im- 
 potent. Of late his bladder had been a little weak. Two years before 
 coming under my care he had lost consciousness suddenly and was 
 aphasic for two days. His capacity to speak in court had been lessened 
 since then. One year before the time when I saw him he had an 
 attack of severe vertigo. Since then his mental powers had been lessened 
 He could not work long, could not concentrate, was forgetful, and had 
 attacks of vertigo. He was very somnolent, sleeping ten hours at night 
 and in the afternoon. He was depressed, emotional and unable to do 
 much work of any kind. His gait and stature were normal, speech 
 clear, handwriting much impaired. The knee jerks and ankle jerks were 
 present, but uneven. The pupils were uneven and did not react to light, 
 but did to accommodation. The left pupil was irregular in shape. The 
 patient had no anesthesias, lightning pains or ataxia. There was tremor of 
 the hands, and the face showed distinct facial tremor. The main mental 
 symptoms were incapacity to work, mental inadequacy, defective memory, 
 emotional excitability (irritability and depression) and somnolence. The 
 physical symptoms were changes in deep reflexes, Argyll-Robertson pupils, 
 facial tremor, defects of handwriting, sexual impotence without local 
 cause, as attested by Dr. Eugene Fuller, who saw him in consultation, and 
 
 4
 
 24 THE CURABILITY OF EARLY PARESIS 
 
 vesical weakness. It was six months before the patient improved very 
 much, but at the end of that time he was very much better, except 
 of the sexual impotence, and the pupils. His memory was good, his 
 somnolence and apathy better. A letter received from him recently states 
 that he is well, nearly three and one half years since I first saw him. 
 
 Such a case as this is illustrative of a type which I have also 
 seen progress till all the marks of paresis are developed. 
 
 Case 9. — J. E., aged 43, single, occupation engineer. The history fur- 
 nished by his family physician, Dr. Parslow, is as follows: The patient's 
 father died of Bright's disease, at 69; the mother was living in good 
 health; he had four sisters, all living. One had epilepsy for some years, 
 but recovered. Three aunts died of tuberculosis. 
 
 The patient was always robust; used alcohol and tobacco moderately. 
 His habits were excellent, with the exception of sexual excess, which 
 undoubtedly made serious inroads on the patient's vitahty. About three 
 weeks after connection, in the latter part of 1901, three hard chancres 
 appeared on the dorsum of the penis, followed by adenitis, roseola, etc. 
 The secondary stage ran a mild course. Mercurial treatment was faith- 
 fully carried out. About one year after the primary sore, the patient was 
 stricken with left hemiplegia. At this time, a neurologist saw him. 
 Mercury by inunction was pushed. The motion of the left arm was 
 seriously impaired, but improved. After the patient was up and around, 
 it was noticed that he would fall asleep at his work, especially after eating; 
 he was very hard to arouse mornings, even after ten or twelve hours' 
 sleep. As he was in charge of complicated machinery, his employers had 
 to displace him. His friends noticed that he acted queerly at times. Dr. 
 Parslow never noticed any delusions or hallucinations. The patient wept 
 easily, and his mental depression was marked; his countenance changed 
 from a bright and intelligent to a dull and stupid expression. He was 
 given iodids in large doses, but failed to improve. 
 
 When examined by me, he still showed some evidences of the left 
 hemiplegia, the arm being somewhat contractured, and there were slight 
 athetoid movements in the left hand. There was no anesthesia or ataxia. 
 The reflexes were exaggerated, more on the left than on the right, but 
 there was no clonus. The pupils were sluggish, but not actually of the 
 Argyll-Robertson type. Mentally, he was simply very slow and forgetful; 
 did not have even the ordinary school knowledge, nor could he recall the 
 ordinary events of the day. He would fall asleep during the daytime 
 and sleep all through the night. He had no cranial nerve palsies ; no 
 speech defects, but had a little tremor of the face and hands. He did not 
 show any actual neglect of the person, and his sphincters were intact. He 
 could read a little and write imperfectly. His condition had been gradu- 
 ally getting worse, notwithstanding large doses of the iodid of potassium, 
 amounting to 120 grams a day.
 
 THE CURABILITY OF EARLY PARESIS 35 
 
 The patient was put on hypodermic injections of saUcylate of mercury, 
 and gradually began to improve, and in about six months time he 
 seemed well, and went back to his work. 
 
 I saw him a year ago, five years after my first visit. He was then 
 well mentally in every way. His speech was good, his memory clear, 
 and he simply had some relics of his old hemiplegia. 
 
 This is a case of cerebral syphilis, but it was passing into de- 
 mentia. The patient already had tremor, sluggish pupils, exag- 
 gerated reflexes. He was dull, slow, had lost his knowledge of 
 things, was extremely forgetful, queer in actions, depressed, emo- 
 tional, somnolent and partially demented. 
 
 Case 10. — E. A. M., male, aged 52, married, with two healthy children, 
 came to see me first in May, 1906, suffering from tabetic pains. He had 
 had a luetic infection at the age of 20, and was thoroughly treated for 
 two years; he had had no luetic manifestations since then. He had been 
 a hard worker at the dry-goods business. His habits were good ; he used 
 no alcohol or tobacco in excess. In 1898 he broke down with what was 
 called " nervous prostration," and was unable to work for about six 
 months. Two years later, in 1900, he began to have the characteristic 
 pains of tabes, and had been treated for these symptoms, and these alone, 
 since that time. 
 
 Status in 1906: The gait was normal; there was slight Brauch-Romberg 
 sign present, slight ataxia of the hands to the finger-nose test. Argyll- 
 Robertson pupils, unequal in size, knee jerks and ankle jerks absent, tremor 
 of the facial muscles and of the hands, no hypotonia, no anesthesia, bladder 
 slow, sexual function very weak, tachycardia, but no valvular lesion. Men- 
 tally, the patient was irritable and quite forgetful; he had a slightly exag- 
 gerated manner, was a little exalte, was easily confused, could not play 
 cards without making mistakes, could not sign his name on account of 
 nervousness and tremor. He was somnolent during the day, falling 
 asleep at his desk, was not able to read except for a few moments, was 
 unable to do his work well, becoming easily confused and exhausted. 
 There was a general change in his character, so marked that his wife 
 came to consult me about it. He had no delusions, but was somewhat 
 depressed. 
 
 The diagnosis, in 1906, was tabes and developing tabo-paresis. No- 
 vember, 1909, after several months rest and treatment, part of the time 
 at a sanitarium, the patient returned to business and he has continued at 
 it ever since. I have seen him at intervals during the past three and 
 a half years. He is now mentally normal ; he is no longer forgetful and 
 can attend to his work. He can write and dictate readily. Facial tremor 
 is gone. The tabetic symptoms are the same, almost exactly, as they 
 were three years ago.
 
 36 THE CURABILITY OF EARLY PARESIS 
 
 Case ii. — W. D., aged 30, married, denies infection. In 1902 he 
 gradually developed a spastic paraplegia with bladder and sexual weakness, 
 the disease taking the course of Erb's syphilitic spinal paralysis. In the 
 fall the patient developed delusions of grandeur, and when examined by 
 me he had all the somatic and mental symptoms of general paresis, with 
 facial tremors, Argyll-Robertson pupils, and involvement of the pyramidal 
 tracts. This diagnosis was confirmed by Dr. Frederick Peterson and the 
 physician in charge of the institution to which the patient was committed. 
 He was insane and delusional for nearly a year, but gradually improved, 
 and has now been practically well of his mental trouble for over seven 
 years. He has not known quite the mental vigor of his former years, 
 and his spinal symptoms have remained about the same. The total dura- 
 tion of the condition is now nearly eight years. 
 
 This is a remission in general paresis, and it is not one of the 
 class of cases on which I base my remarks. It is admitted by all 
 that there may be long remissions in general paresis. 
 
 I could cite other cases from my notes, but I prefer to get the 
 evidence of other neurologists, and Dr. Joseph Collins has kindly 
 placed the two following cases at my disposal : 
 
 Case 12. — A man, aged 45, stock broker, unmarried, was seen May 
 31, 1904. He had had syphiHs when 23, an apparently moderate infection, 
 treated by a prominent speciaHst for three years and pronounced cured. 
 When 31 years old the patient had an attack of diphtheria; when 38, an 
 attack of typhoid fever. 
 
 The first symptoms of the present disorder, of which the patient is 
 cognizant, occurred in 1903. He was in bathing. The propinquity of a 
 certain person was responsible for extreme erethism, followed after a 
 long time by orgasm. The patient experienced a profoundly disagreeable 
 sensation in the head, and had a feeling of confusion and syncope. Fol- 
 lowing this, he was in bed for a fortnight, and his physician who treated 
 him said that he had a heat-stroke. After that time the patient was 
 subject to periods of profound depression. He lacked initiative, was 
 moody, sullen, unsociable, and impotent. He frequently made mistakes 
 in his orders and thought he had to give up business. Depression was his 
 worst symptom. The pupils were unequal; one knee jerk was absent, 
 and there was distinct slowing of speech. This man took an enormous 
 amount of mercury, by hypodermic injections and inunctions, and is 
 today practically well. The physical signs remain the same, save that the 
 speech has become distinct. He is able to transact his business as well as 
 ever. 
 
 Case 13. — A man, aged 46, had syphilis when 21 ; he was rather 
 alcoholic. When 38 years old he developed symptoms of mental con- 
 fusion, associated at times with violence, but depression was his chief
 
 THE CURABILITY OF EARLY PARESIS 3/ 
 
 symptom. Gradually he became indifferent to his family, exhibited loss of 
 self-control and was most easily excited and annoyed. Examination 
 showed pupils that were unresponsive to light, slight tremor of the lips, 
 tongue and hands, and exaggerated knee jerks. He seemed to have in- 
 sight into his condition and explained his inability to work by saying 
 that he was weak. He would frequently make mistakes in writing, how- 
 ever, and displayed evidences of marked forgetfulness. He was put 
 under intensive mercurial treatment, and today, six years after I first 
 saw him, he is running a store. 
 
 The question in all these cases, of course, comes up whether 
 these patients really were suffering from paresis in an extremely 
 early stage. Some authorities seem to take the position that we 
 can never be sure we have a case of paresis until the patient is 
 dead, and the characteristic anatomic changes are found in the 
 cortex of the brain. This anatomic test of the existence of 
 paresis is an unworkable one, and would make the talents and 
 acuteness of the clinician practically of no value. Besides, it 
 seems to me to be utterly without foundation. I do not believe 
 that in the very early stages of paresis any anatomic change exists 
 which could be detected by the microscope, and if we have to 
 wait for our diagnosis of the disease until these anatomic changes 
 occur, I can well agree that the prognosis must always be hope- 
 less. But it is my conviction that we can recognize the malady 
 before any appreciable changes do occur, or at least, changes 
 which are beyond hope of repair or arrest. Let me illustrate this 
 position by the following history : 
 
 Case 14. — A young man, a lawyer, aged 33, was infected with syphilis 
 about eleven years before he was seen by me. He was treated for the 
 disease continuously for two years, and after that period, every six months, 
 for about six years. He continued his professional work, and was very 
 successful in it, until about a year before I saw him, when he suffered 
 from symptoms of what was thought to be neurasthenia. He was treated 
 on this basis and went out West, took active exercise on horseback. He 
 improved somewhat, but then became considerably worse, and was finally 
 brought to me in January, 1909, when he had distinctly the symptoms of 
 paresis — forgetfulness, inability to concentrate, confusion of ideas, irrita- 
 bility, a good deal of mental depression, and certain almost delusional 
 ideas regarding the way in which he was treated by his friends. Phys- 
 ically, he had distinct and characteristic dysarthria, tremors of the face 
 and hands, exaggerated reflexes, and Argyll-Robertson pupils. The 
 Wassermann test was positive. He improved a little for a time, but at
 
 38 THE CURABILITY OF EARLY PARESIS 
 
 the end of the following summer he was distinctly demented and delu- 
 sional, and had all the characteristic physical symptoms of general paresis. 
 These progressed, and he is now in the third stage of the malady. 
 
 The point of interest in this case is this : On inquiring carefully 
 about the patient's earlier years, I found that five years before I 
 had seen him, he had had an attack of mental depression, of a 
 somewhat hypochondriacal type, such as so frequently ushers in 
 paresis. This had occurred without special cause, and in a man 
 whose habits were good, and who had inherited a sound consti- 
 tution. I further learned that after he recovered from this 
 depression he had been a little different in temperament and char- 
 acter, a little more irritable and unreasonable, a little more ego- 
 tistical and expansive than usual, his friends thinking that he was 
 simply rather more conceited and difficult to get on with than 
 before. But, in the light of subsequent events, it seems clear that 
 these were the mental forerunners of his later attack, because 
 when the later attack came on, all these characteristics were simply 
 very greatly exaggerated. Thus, it seems that this attack of 
 paresis can be traced back to a period of five years, during which 
 time the patient achieved a really brilliant success in his pro- 
 fession, transacting his work effectively, and not suffering from 
 any physical troubles whatever. It seems incredible that during 
 all these years of successful professional work and social activity, 
 he had any serious degenerative changes in the cortex of the brain, 
 which changes are supposed to be necessary to enable one to make 
 a diagnosis of paresis. 
 
 If the history of cases of paresis could be traced back in all 
 instances, to the very remotest beginning, I believe that in a good 
 many instances this prolonged preliminary period of slight mental 
 perversion might be discovered, and in this case I think that if 
 treatment had been undertaken along proper lines three years 
 before, or two years before, the malady might have been kept in 
 check. 
 
 The onset of a parasyphilis, occurring in persons who have had 
 an infection, takes place in different ways as follows : 
 
 I. Acute symptoms of syphilitic exudates in the brain, ending 
 promptly or later in paresis, or ending in cure, with or without 
 mental symptoms, or ending in some deterioration with final 
 serious cerebral vascular changes.
 
 THE CURABILITY OF EARLY PARESIS 39 
 
 2. Acute mental symptoms, maniac or melancholic, ending in 
 cure or paresis. 
 
 3. Tabetic and paretic symptoms, ending in taboparesis or in 
 tabes with arrest of paresis. 
 
 4. Insidious mental and physical deterioration, ending in paresis. 
 The above initial conditions all may or may not end in paresis, 
 
 depending on treatment, the constitution of the patient, and the 
 intensity of the infection. Often they go on until nearly every 
 symptom of paresis appears, yet they are even then arrested. The 
 clinical phenomena, from the beginning to near the end, are pro- 
 duced by the same pathologic agent, and often can be controlled 
 by treatment, even when the signs are ominously identical with 
 early symptoms of general paralysis. This is what I mean by 
 " cure of early paresis."
 
 THE DIAGNOSIS OF GENERAL PARALYSIS^ 
 By C. Macfie Campbell, M.D. 
 
 ASSISTANT PHYSICIAN BLOOMINGDALE HOSPITAL, NEW YORK 
 
 The differential diagnosis of general paralysis is an extremely 
 wide subject in view of the polymorphous character of the dis- 
 ease. Not only do various forms of organic brain disease present 
 clinical pictures difficult to distinguish from general paralysis, but 
 the latter may first manifest itself in a form difficult to distin- 
 guish from that of one of the so-called functional psychoses ; thus 
 a manic attack may be the first expression of a general paralysis. 
 
 The question of the early diagnosis of general paralysis, and 
 the discussion of those symptoms accompanying a so-called func- 
 tional symptom-complex which enable one to diagnose the para- 
 lytic process underlying it, will no doubt be taken up by others. 
 
 I propose to contribute to the discussion several cases where 
 the difficulty of diagnosis was not merely transitory, nor due to 
 the disease being in an incipient stage ; but where in a well- 
 advanced stage of the disease it was extremely difficult to know 
 how much weight to lay upon the various symptoms, and to come 
 to a conclusion as to the process at the bottom of the disease. 
 
 It will be necessary in regard to some of these cases to refer 
 to the result of the anatomical examination which decided the 
 diagnosis ; before doing so, and in order not to beg the question, 
 one must first be clear as to the present state of our knowledge of 
 the histopathology of general paralysis. 
 
 The most satisfactory and most recent statement on that topic 
 is to be found in the first volume of Nissl's publications from the 
 laboratory of the Heidelberg clinic. The volume contains the 
 results of the work of Alzheimer and of Nissl ; both, working at 
 the same question upon independent material, came to the same 
 conclusion, that in general paralysis there are always characteristic 
 histopathological changes which enable a positive diagnosis to be 
 made. A slight reservation must be made with regard to certain 
 cases of idiocy upon the basis of a non-purulent encephalitis, with 
 
 ^ Read before the New York Psychiatrical Society, November 7, 1906. 
 
 41
 
 42 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 regard to which there is not as yet sufficient material for definite 
 statements to be made. In the work referred to, Nissl discusses 
 in great detail certain morphological questions, and emphasizes 
 the wide biological and pathological issues, while Alzheimer limits 
 himself more strictly to the immediate needs of histopathological 
 and clinical differentiation. Reference, therefore, will be made 
 chiefly to the work of Alzheimer. 
 
 The material which Alzheimer used consisted of 170 consecu- 
 tive cases of clinically undoubted general paralysis ; in every case 
 he found certain histological changes in the cortex ; he concluded, 
 therefore, that he had a definite anatomical criterion to apply to 
 all cases of doubtful clinical diagnosis. 
 
 This anatomical criterion is not claimed as forming the essence 
 of the paralytic process ; the same cortical changes were found by 
 Nissl in a dog and two rabbits ; they form, however, a trustworthy 
 empirical criterion, which every case claimed as general paralysis 
 must satisfy. 
 
 Macroscopic examination is not sufficient to settle conclusively 
 a disputed case; at the autopsy the brain of a general paralytic 
 may show no macroscopic evidence of general paralysis; on the 
 other hand Alzheimer refers to a case diagnosed in life as senile 
 dementia, which presented at the autopsy thickening of the cal- 
 varium with disappearance of the diploe, thickening and opacity 
 of the pia with pial collections of fluid, hydrocephalus internus 
 and externus, ependymal granulations, marked atrophy of the 
 brain, especially in the frontal region ; microscopical examination, 
 however, confirmed the clinical diagnosis of senile dementia. 
 Such a case demonstrates the necessity of microscopical exami- 
 nation. 
 
 The following is a brief summary of the histological changes 
 characteristic of general paralysis. 
 
 I. In every case the pia mater shows diffuse changes, usually 
 most marked over the frontal lobe ; these changes consist essen- 
 tially of an infiltration of the pia with cellular elements, plasma- 
 cells, lymphocytes and mast-cells ; in addition the vessel-walls show 
 progressive and regressive changes. 
 
 With regard to the cortex in general paralysis it is convenient 
 to discuss first the mesodermal elements and then the ectodermal 
 elements.
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 43 
 
 2. In every case there is proliferation of the endothehal cells 
 of the vessels with a marked tendency to the new formation of 
 vessels through sprouting and vascularization of the proliferated 
 intima. There is increase of the elastica and proliferation of the 
 adventitia. There is widening and infiltration of the lymph spaces, 
 which exist in the adventitial coat of the vessel wall. Among the 
 infiltrating cells, plasma-cells are the most numerous: they are 
 never absent in a case of general paralysis, even in the most 
 acute. Lymphocytes and mast-cells may also be found in the 
 infiltrate. In advanced cases the vessel walls show regressive 
 changes. Regularly in general paralysis, we find long rod-shaped 
 or sausage-shaped cells in the cortex, their long diameter tending 
 to run parallel with the medullary rays. 
 
 As to the ectodermal elements : 
 
 3. The nerve-cells show a great variety of degenerative forms, 
 the meaning of which is as yet quite obscure ; in advanced cases 
 the nerve cells have in part disappeared. The usual orderly 
 arrangement of the cells in the cortex is more or less disturbed. 
 There is usually a considerable degeneration of the medullated 
 fibers in the cortex. 
 
 With regard to the non-nervous ectodermal tissue, i. e., the 
 neuroglia : 
 
 4. There is always a marked proliferation of the glia ; this pro- 
 liferation leads at first to the formation of numerous large glia 
 cells which form a large number of fibers, and, in very advanced 
 cases, dense tissue of thick glia fibers. The most marked increase 
 is situated in the molecular layer and along the vessel sheaths. 
 
 The changes in the rest of the nervous system in general paral- 
 ysis, the nature and degree of aflection of the central ganglia, 
 cerebellum, cord, etc., need not at present be discussed. 
 
 Lissauer has described cases of atypical general paralysis, in 
 which focal symptoms precede the symptoms of mental disorder; 
 in these cases one frequently has from time to time apoplectiform 
 attacks, each attack leaving the same residual defect — hemiparesis, 
 hemiplegia, aphasia — which is frequently transitory. 
 
 In such cases the typical cortical changes of general paralysis 
 are found, the focal symptoms not being due to the addition of 
 syphilitic or arteriosclerotic or other lesions, but to the unusual 
 severity of the process in certain areas, the central convolutions,
 
 44 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 the temporal lobe, etc. In other cases, where the distribution of 
 the process has at first been the usual one, later in the disease the 
 changes may become most severe in the posterior half of the 
 cortex and focal symptoms may then develop. Transition forms 
 between the typical and the atypical general paralysis are numerous. 
 
 In certain cases we find general paralysis associated with tabes, 
 and that may occur in two ways : tabetic changes may develop 
 during the course of general paralysis, or a person, who has for 
 long been a tabetic, may later show signs of general paralysis. 
 The tabes of a general paralytic is histologically little diflferent 
 from that of a non-paralytic ; dififerent systems in the posterior 
 columns, however, tend to be first affected and a slight cellular 
 exudate is frequently seen in the posterior columns of the general 
 paralytic with tabes, but has not been observed by Alzheimer in 
 tabes itself. 
 
 In general paralysis, there is a constant histopathological pic- 
 ture. Can one always distinguish this from the picture found in 
 cases of alcoholism, senile dementia, arteriosclerotic brain disorder 
 and brain syphilis? In other words, in doubtful clinical cases, 
 will microscopical examination enable one to differentiate between 
 these groups? 
 
 With regard to the first three groups there is little difficulty, 
 and it is not necessary to go over the differences in the degenera- 
 tive changes found in each ; a diffuse perivascular infiltrate with 
 plasma cells is not found in any of these conditions. 
 
 The differential diagnosis between general paralysis and brain 
 syphilis is more difficult, but is, however, always possible ; at least, 
 one can always say whether the case is general paralysis or not; 
 it is not always easy to determine whether, in addition, there 
 is a syphilitic element present. Brain syphilis is a general term 
 which includes gumma of the brain, syphilitic endarteritis of the 
 cerebral vessels, either of the large vessels (Heubner's form), or 
 of the terminal vessels (Nissl's non-inflammatory form of brain 
 syphilis), and finally syphilitic meningo-encephalitis, with or with- 
 out gummatous formation. Each of these presents a definite histo- 
 pathological picture and can be separated from general paralysis. 
 The most difficult cases are those belonging to the last group — i. e., 
 syphilitic meningo-encephalitis ; careful microscopical examination 
 enables one here, too, to separate the two conditions. The pictures in
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 45 
 
 Alzheimer's work illustrate well the two conditions. The meningo- 
 encephalitis shows the most marked infiltration in the pia, which, 
 along with the vessel walls and the cranial nerves passing through 
 the membranes, is infiltrated with lymphocytes. The process 
 spreads from the pia into the cortex, afifecting the superficial 
 layers more than the deeper, sometimes obliterating the border 
 between pia and cortex. Where the affection of the pia is local- 
 ized the cortical changes show a similarly circumscribed distri- 
 bution. The condition may be complicated by gummatous nodes, 
 and by softening due to thrombosis. 
 
 Such a picture is quite different from that of general paralysis 
 where the severity of the cortical change does not necessarily cor- 
 respond with that of the meningeal change in the same neighbor- 
 hood, and where the cortex shows parenchymatous degeneration 
 and vascular changes diffusely distributed throughout the whole 
 cortex. The behavior of the cells of the infiltrate is different in 
 the two conditions. In the syphilitic meningitis the infiltrate, 
 composed chiefly of lymphocytes, is not arrested by the limits of 
 the vessel walls nor of the nerves which pass through the pia, it 
 penetrates both. The cell changes in the pia do not show the 
 variety of progressive and regressive forms found in general 
 paralysis. 
 
 A syphilitic meningo-encephalitis of the convexity is almost 
 always accompanied by a syphilitic meningo-myelitis. 
 
 Mahaim says that it is impossible to differentiate general paral- 
 ysis from diffuse brain syphilis ; but the form which causes most 
 difficulty is that already discussed and the individuality of which 
 has been established. His views are based upon an insufficient 
 study of the infiltrate in the various conditions. 
 
 Klippel considers general paralysis a clinical syndrome which 
 may arise on an alcoholic, syphilitic, arteriosclerotic or other 
 basis. He bases this statement upon quite erroneous ideas, the 
 criticism of which would necessitate a somewhat detailed state- 
 ment of his position. As a matter of fact, the present state of 
 our knowledge of pathological anatomy has enabled us to dis- 
 tinctly separate the various processes, arteriosclerotic, senile, alco- 
 holic, syphilitic and general paralytic; if then, clinically, one is 
 not always able to distinguish between these groups, that is no 
 reason for refusing to recognize them as different conditions ; it
 
 46 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 is simply a reason to push further our dinical analysis. The clin- 
 ical differentiation of these groups is not so far forward as the 
 anatomical differentiation. There is an urgent necessity for well- 
 analyzed clinical material, so that we can make full use of the 
 assistance which microscopical examination offers us. From this 
 point of view the following cases are presented. 
 
 Case i. — William C. ; 47 years of age, admitted to Manhattan State 
 Hospital on August 25, 1905; died May 3, 1906. 
 
 His father was alcoholic; he himself was a neurotic child, had night 
 terrors, walked and talked in his sleep. He developed normally, later 
 became addicted to alcohol, married in 1891, having had a chancre six 
 months previously, for which he received only three months' treatment. 
 He infected his wife, and she had a disastrous series of pregnancies, but 
 finally a living and healthy child. Ever since his marriage, the patient 
 drank immoderately, indulged in excessive sexual intercourse, tormented 
 his wife with his morbid jealousy and suspicions, so that she left him 
 more than once. As far back as 1897, he would suspect poison, and 
 imagine that his relatives and associates dealt unfairly with him; his 
 waking thought was apparently considerably influenced by dreams. 
 
 Focal symptoms first came on in 1900. In 1900, towards the end of 
 summer, his wife noticed squint of the right eye; this persisted till 
 November. In September of the same year, he had an attack of dysar- 
 thria and staggering; no definite weakness of the limbs of either side was 
 noticed. He recovered after two months in bed, his speech returning ap- 
 parently to its normal condition. He was able to resume work. 
 
 1901. Again fatigued and without appetite; he lost the power of his 
 right leg " from the knee downwards," the weakness not being abrupt 
 in onset but coming on in the course of a few days ; speech was thick, 
 
 1901-1903. Unable to work; he dragged the right leg; two or three 
 sudden attacks of paralysis of the right arm of one half day's duration, 
 with weakness of the right side for about a week. 
 
 1903. One day he suddenly fell; when seen one hour later, he was a 
 little excited, able to speak, his left arm suddenly became paralyzed, he 
 could not speak for one hour ; he was then able to walk, went to work the 
 next day. 
 
 1903-1905. Worked as night watchman, gradually became weaker, did 
 not recognize that he was an invalid, made light of his hemiplegia. 
 
 1904. Occasional difficulty in controlling his urine. 
 
 1905. July. One day at noon he was found unconscious; half an 
 hour later he was excited, but unable to speak, he made signs, then said 
 " that's better." For one week he was semi-conscious, disoriented, didn't 
 know his wife; he remained at home for five weeks, was disoriented, had 
 hallucinations of sight — "didn't you see them men?" — thought medicine 
 was poison. In Bellevue Hospital he thought he was in St. Stephen's 
 Church, had no idea of why he was there.
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 47 
 
 On admission to M. S. H. he was at first excited and pugnacious, but 
 on examination quiet and agreeable, anxious to go home; he was able to 
 maintain a conversation. He was happy, felt first-rate, did not resent 
 being with crazy people ; " this is Manhattan Life Insurance-Bellevue 
 Hospital," he gave the date correctly. He had fair memory of remote 
 and recent events, but his dates showed discrepancies, e. g., " this is 1906 
 — born in 1862 — 47 years old." Dilapidation of general knowledge; poor 
 retention ; no insight. 
 
 August-October. Mildly demented, whimpering easily over his de- 
 tention. 
 
 October 25th. Ptosis of the left eye developed, became complete in a 
 week, cleared up after four weeks. 
 
 Physical Status. — October 25, 1905. There was weakness of the right 
 face, arm and leg. Knee-jerks and Achilles-jerks exaggerated, especially 
 the right. The gait was rather unsteady as well as having the " mow- 
 ing" character. Babinski reflex on both sides. Slight ptosis of the left 
 eye; left pupil dilated, did not react to light nor on accommodation; right 
 pupil smaller, reacted sluggishly to light. Fundi normal. Speech: slur- 
 ring, slightly sticking, without omissions or transpositions, but with occa- 
 sional insertion of r. Writing: tremulous with omissions and distortions, 
 e. g., " meth-espical" (methodist episcopal), " bittililery " (artillery). 
 There was no gross sensory disorder. Lymphocytosis of the cerebro- 
 spinal fluid. 
 
 During his stay in hospital, the patient continued to present this picture 
 of mild general dilapidation, with no adequate realization of the mental 
 and physical impairment, but showing no definite expansiveness nor 
 other abnormal mental trend while in hospital. 
 
 On April 30, 1906, the patient had a general convulsion, became un- 
 conscious; he died on May 3. 
 
 The question whether one had a right in this case to consider 
 a diagnosis of general paralysis as established was discussed 
 during the lifetime of the patient. Our present knowledge of 
 the symptoms of brain syphilis is inadequate and based on a very 
 limited material, and it was felt that to exclude the diagnosis of 
 brain syphilis altogether was to assume a knowledge of the same 
 which we are far from possessing. 
 
 The possibility of brain syphilis was suggested by the variety of 
 the neurological symptoms — squint in 1900, a series of rightrsided 
 attacks with dysarthria from 1901 to 1903, transitory paralysis 
 of the left arm in 1903 (if the wife's statement can be relied on), 
 the apoplectiform attack preceding commitment, the transitory 
 ptosis of the left eye which developed in hospital. Such a train 
 of symptoms seemed in keeping with what we know of the course
 
 48 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 of brain syphilis, and it was considered possible that the under- 
 lying anatomical process might be a syphilitic meningo-encephalitis 
 with syphilitic endarteritis, the hemiplegic attacks being due to 
 the vascular changes ; the mild dementia might then be regarded 
 as an ordinary post-apoplectic dementia. 
 
 This hypothesis, however, did not seem to explain various fea- 
 tures in the case. The want of insight into his mental and physical 
 impairment, and his general optimism seemed to be more than is 
 usual in a non-paralytic dementia; it is true that in some cases 
 of the latter a similar attitude may be seen, and the difference in 
 degree is difficult to estimate. Repeated tests of his memory 
 showed a striking difficulty in handling dates, and an inability to 
 correct discrepancies; e. g. : Age? "48." Present year? "1906, 
 then I must be 58." Are you 58? " No — that would be 1858 — I 
 would be 50 then — this is only 6 — that would be right, 58 years 
 of age." 58 years of age? "Yes, sir." Are you 50 years of age ? 
 " No, I would be 48 — I made a mistake — 48 and 58 — 1858, and 
 then 50 — 40 more — would be 1906, — wouldn't it — 18 and 46 
 more." At the same time the patient showed great pertinacity in 
 trying to correct discrepancies. 
 
 The speech also (e. g., bittililery) seemed to show a more pro- 
 found defect in the grasp of words than is usually met with in 
 brain syphilis. 
 
 The physical symptom-complex seemed consistent with either 
 view of the case, although the variety of the neurological symp- 
 toms pointed rather toward brain syphilis. 
 
 On the basis of the above analysis, the conclusion was that the 
 patient was probably a case of general paralysis, but that, in so 
 far as we are not entitled to deny the possibility of the presence 
 of the above mental defects in brain syphilis, and in view of the 
 neurological course, the diagnosis of general paralysis was not 
 considered as established. 
 
 At the autopsy there were noted slight atrophy of the frontal 
 region, rather more marked on the left side, slight general thick- 
 ening of the pia, granulations in the fourth ventricle. In the knee 
 of the right internal capsule there was an old focus of softening, 
 and another in the left side of the hind brain, involving the pyra- 
 midal fibers. There was a gumma in the left centrum semiovale, 
 connected with the pia of the insula, another in the right parieto-
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 49 
 
 occipital fissure. Histological examination showed a syphilitic 
 meningitis, of varying grade, with slight extension into the cortex. 
 The case, therefore, was one of cerebral syphilis. 
 
 Case 2.— J. L. W.; 43; admitted to M. S. H. August 4, 1906; died 
 August 26, 1906. 
 
 The patient was a journalist, who, in 1898, at the age of 35, had a 
 chancre for which he was treated for 4-6 months. In the summer of 
 1901 he had diplopia, which improved with two months' treatment. In 
 April, 1902, he one day lost power in his left arm; next day his whole 
 left side was affected ; there was no loss of consciousness. He was taken 
 to a hospital where complete left hemiplegia without impairment of 
 tactile sensibiHty was observed. He was treated with potassium iodide, 
 was discharged after four weeks as improved; the diagnosis was cerebral 
 syphilis. 
 
 November, 1902, he retired one night dizzy and nauseated; during the 
 night he woke up with left-sided paralysis; there was twitching of the 
 left arm, leg and side of the face for four hours ; he could not speak, 
 was conscious, attracted attention by knocking down a screen. 
 
 He was again treated in the same hospital with sodium iodide, and 
 hypodermics of bichloride of mercury, was discharged after 19 days, 
 improved ; diagnosis : cerebral syphilis. 
 
 After discharge he only occasionally took medicine; from time to 
 time he had headache. In October, 1905, the patient noticed that the left 
 leg was becoming weaker; he received glutal injections for one month. 
 In the autumn of 1905 his work apparently was inefficient, he was dis- 
 charged from the paper on which he worked. In January, 1906, he twice 
 (on the fifteenth and twenty-second) fell abruptly without dizziness or 
 loss of consciousness; he was able to raise himself and walk home. 
 
 He was admitted to Bellevue Hospital, January 25, complaining of 
 having fallen in the street, of progressive weakness of the left leg, and 
 of loss of memory. The diagnosis of cerebral syphilis was made 
 and the patient was given potassium iodide up to 39c grains a day, 
 and was also treated with hypodermic mercurial injections. From the 
 beginning of his stay in B. H. he showed mental symptoms, was irrational. 
 Soon after admission, he tried to get out of bed and take a stroll along the 
 river. He was restless and noisy at times, sometimes mildly delirious, 
 rambling about imaginary things. In February he had four convulsions 
 one night. During the latter half of his stay in Bellevue he was rather 
 irritable, and several times tried to escape. In June he was noticed to 
 stammer badly, saw objects dimly, was generally muddled. His pupils 
 which were noted as reacting normally on admission, were noted as 
 irregular and slow to react in June. 
 
 On admission to M. S. H. the patient was childishly happy, affable, 
 loquacious, amused by details, frequently laughing without much provo- 
 cation. He had no grounds for his euphoria, admitted that he had " not a 
 
 5
 
 50 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 d-d cent," and as to his physical condition he said, " It's a terrible plight, 
 I don't suppose I will ever get well again " ; he laughed cheerfully at the 
 position. 
 
 He knew he was in Manhattan State Hospital on Ward's Island, gave 
 the date correctly. He complained spontaneously of his memory being 
 poor, and in giving his history he made several careless mistakes; these, 
 however, he was able to correct ; e. g., left school at i6, was in lawyer's 
 office for five years, then set up in practice at 23. He said that he had 
 been ten years in New York, had been working twelve years for a New 
 York newspaper; he corrected himself when the discrepancy was referred 
 to. 
 
 He had a fair memory for the period since his first attack in 1901, 
 although he said that the interval between the two admissions to the 
 first hospital was 18 months (it was 6). Although his retention of a 
 test name and number was good, he was very much confused over the 
 incidents of the immediate past. On the day of admission he thought that 
 he had been two nights on the island, and shortly after admission he 
 confused M. S. H. with B. H., thought he had been there several months, 
 said that the ward physician had vaccinated him at B. H. ; and fabricated 
 an incident of calling on the same physician at B. H. ; he was confused 
 as to the time of day; in the evening he said "I thought it was about 
 eleven o'clock, I remember now I had dinner." He had some difficulty 
 in giving simple facts ; the name of the river Hudson, of the governor, 
 etc., would escape him ; the cause of the war with Spain was some diffi- 
 culty over the tariff. 
 
 The patient admitted that he had a bad memory, but did not realize 
 the extent of his mental impairment, nor that his mood was at all ab- 
 normal. He had no absurd ideas, admitted having had a delirious episode 
 and hallucinations at B. H. 
 
 Physically he had the well-marked residuals of a left-sided hemiplegia — 
 left knee-jerk more exaggerated than the right, left ankle clonus and 
 Babinski reflex, weakness of left arm and leg, none of the face. The 
 patient was clumsy in all movements ; in walking he not only dragged the 
 left leg, but he walked with a broad base of support, staggered from side 
 to side. His difficulty in maintaining the erect position was increased 
 on closing the eyes. There was tremor of the muscles of the face and 
 of the hands ; his speech was tremulous and sticking, but without trans- 
 position of syllables or distortion of the words. His writing was ex- 
 tremely tremulous, the words were crowded up into one corner of the 
 paper, but were correctly written. The pupils were dilated, equal, irregu- 
 lar; they reacted well to light and on accommodation, also consensually. 
 The radial arteries showed no marked thickening. 
 
 On August 14, after ten days in hospital, the patient had a series of 
 convulsions in which the right side twitched more than the left ; the con- 
 vulsions left him with marked aphasic symptoms, paraphasic utterances 
 and perseveration, and with weakness of the right arm, but without sign 
 of Babinski on the right side. The pupils reacted very slightly to light.
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 5 1 
 
 The symptoms showed variable intensity for the next week, and the 
 patient died on August 26, three weeks after admission. 
 
 The diagnosis during the Hfe of the patient was rather doubtful, 
 and previous to admission he had been treated as a case of brain 
 syphiHs. In the mental status one of the most important features 
 was the presence of a striking anomaly of mood. The first 
 patient made light of his bodily condition, talked of it as of no 
 importance, and his optimism as to the future and as to his ability 
 to work was evidence of impaired judgment. The second patient, 
 on the contrary, recognized his bodily impairment — " It's a ter- 
 rible plight, I don't suppose I will ever get well again " — but this 
 intellectual recognition of his plight had no counterpart in his 
 mood; he felt in the best of spirits, was not at all depressed, 
 laughed cheerfully even when his condition was discussed, talked 
 of inviting some friends to come up and take him for a drive. 
 Wernicke has emphasized the importance, as a sign of general 
 paralysis, of any tendency on the part of a patient to minimize 
 physical impairment ; it may, however, be well-marked in non- 
 paralytic dementia. On the other hand this definite primary 
 euphoria, not associated with underestimation of the physical im- 
 pairment, seemed to point very strongly to a paralytic process. 
 
 The euphoria here was accompanied neither by underestimation 
 of the physical impairment, by delusions of grandeur of any de- 
 scription, nor by any grandiose plans for future work. 
 
 The patient's memory of the recent past showed a partial reten- 
 tion of the incidents with complete confusion as to their actual 
 sequence and relation, and with a tendency to fabricate ; such a 
 confused account, in a patient who is alert and cooperating well, 
 is to be distinguished from the inconsistent and confused answers 
 of a torpid patient giving poor cooperation. 
 
 The euphoria and particular memory defect, in association with 
 the patient's alert attitude during examination, did not seem to be 
 adequately explained by any form of cerebral syphilis, but pointed 
 to a general paralytic process. The physical symptom-complex 
 with the marked ataxia, difficulty in maintaining the upright posi- 
 tion increased on closure of the eyes, marked jerky tremor of the 
 hands and face with tremulous and sticking speech, seemed also 
 to be explained only on the basis of general paralysis ; the ataxia 
 and the degree of the tremor were the symptoms upon which
 
 52 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 special weight was laid. The varied nature of the neurological 
 symptoms — diplopia in 1901, two left-sided hemiplegic attacks in 
 1902, the latter with inability to speak for four hours although 
 conscious, the final convulsions with irritative symptoms on the 
 right side followed by paralytic symptoms on the same side, and 
 by an aphasic disorder — and the frequent headache during the 
 course of the disease suggested brain syphilis, but did not exclude 
 general paralysis ; the negative result of treatment pointed to the 
 latter. 
 
 On the above grounds it was felt that one was here justified in 
 diagnosing general paralysis. 
 
 The brain showed distinct cortical atrophy over the frontal 
 region on both sides, with well-marked ependymal granulations. 
 The cortex showed the typical changes of general paralysis with a 
 very pronounced perivascular infiltrate. In addition there was a 
 cortical softening in the right second frontal convolution and an 
 old focus of softening in the head of the caudate nucleus involving 
 the internal capsule. 
 
 In the two cases analyzed the attitude of the patient towards his 
 physical disorder and the nature of the memory defect have been 
 discussed in some detail. It may be useful at this stage, for the 
 sake of differentiation, to give a brief summary of a patient who 
 for years was regarded as a case of general paralysis, but on closer 
 consideration was found to be a case of organic dementia on the 
 basis of vascular brain-disease and alcoholism. 
 
 Case 3. — Cuma G., aged 39; admitted January 11, 1901. 
 
 The patient is a Frenchman, right-handed, born 1862, of extremely 
 alcoholic habits with a history of syphilis at 20 without medical treatment. 
 After a trauma in 1890 he was more susceptible to alcohol than previously. 
 For years before admission he treated his wife outrageously, did no 
 work, drank at home. In 1899 he had an apoplectiform attack, leaving a 
 left-sided hemiplegia ; for five days he could not speak, his words gradually 
 came back, but his speech remained seriously impaired. (The record at 
 the French Hospital has been lost.) He was rather violent and abusive 
 in the hospital ; he was taken home after two weeks, continued to show 
 the same behavior as before, was admitted to M. S. H. in igoi. The 
 diagnosis of general paralysis was made on an insufficient basis; the 
 difficulty of language and the defective articulation created the impression 
 of a deeper dementia than really existed, and this impression was fostered 
 by his rather fatuous chuckle. 
 
 The patient has at the present date (November, 1906), the residuals
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 53 
 
 of a left-sided hemiplegia; his speech is almost unintelligible and pre- 
 sents the characteristics of a pseudo-bulbar disorder. The pupils react 
 well. His mood is one of mild discontent with detention, but during 
 conversation he is usually good-natured, chuckles over references to his 
 past. The special points for which I bring the case forward are the 
 defect of insight which the patient shows and the nature of his memory 
 defect. He appears a little surprised when the physician tells him that 
 he is almost unintelligible, and that his gait is impaired and that he 
 could not get work; he grins, says that he is all right and that he can 
 again get a place as glass-polisher and earn eighteen dollars a week. 
 
 The second point is the memory defect of the alcoholic and hemi- 
 plegic Frenchman. His memory is seriously impaired; at one time he 
 says he was married in the City Hall, New York, then again that he 
 was married in France. He says that he was already at work during the 
 Franco- Prussian war; as a matter of fact he was not ten at the time 
 He gives the ages of his children incorrectely. He gives his age as 49 — 
 it is 44; the present year is 1889. When one tests his memory, he re- 
 peatedly answers " I don't know ; I can't tell," seems to make no effort 
 to remember; if one answer contradict the previous one, he is not em- 
 barrassed, makes no attempt to reconcile the two statements ; he does not 
 fumble around with numbers; the test has no interest for him, he needs 
 repeatedly to be urged before he will give a precise number. This in- 
 difference to the test, the careless answers when much urged, the refusal 
 to try and reconcile contradictory statements, form a different reaction 
 from the marked fumbling with dates and unsuccessful endeavor to hold a 
 series of correct data together, which the typical general paralytic shows.* 
 
 The discussion of these three cases has given rather a negative 
 than a positive result, and suggests caution in the use of certain 
 defect symptoms as differential points. 
 
 In the next two cases the mental defect symptoms are less 
 marked and more difficult to use, and it is on more transient fea- 
 tures in the mental picture and on the physical symptoms that 
 the diagnosis rests. 
 
 The cases have not yet come to autopsy ; perhaps some may hold 
 that the diagnosis has not been established. (January, 191 1. The 
 second patient, J. W. G., remains practically in the same condition 
 as when this paper was read and this want of progression of the 
 symptoms makes the diagnosis still more problematical. The pa- 
 
 *The patient died suddenly on May 8, 1911, the neurological symptoms 
 having shown little damage. The brain showed many foci of softening, 
 involving the white matter and the basal nuclei ; there was no evidence of 
 general paralysis.
 
 54 
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 tient J. A. S. has shown little physical change, while an expansive 
 trend has become rather more prominent.) 
 
 Case 4.— James A. S., 47. admitted April 25, 1905. 
 The patient was from his earliest years accustomed to take alcohol, 
 and ever since his marriage in 1885 he has drunk to excess, treated his 
 wife outrageously, gone with other women, spent most of his money on 
 the race-track. He was a very efficient book-keeper, and notwithstanding 
 his drunken habits he was earning $25 a week at the time of his hemi- 
 plegic attack in 1900. 
 
 When a youth of 16 or 17, he had a soft sore which healed in six 
 weeks ; he had no secondaries and a doctor said that it was not syphilis. 
 
 In 1899 he one day came home, said that he had lost himself and 
 could not remember where he lived ; there was no marked local weakness, 
 but both he and his wife noticed that one pupil was larger than the 
 other. The doctor diagnosed a slight stroke of paralysis. During the next 
 year he had several transitory attacks of dizziness. 
 
 In 1900, while he was dressing, one leg became weak, he fainted. He 
 had a left-sided hemiplegia, affecting the face and extremities. For a 
 week or more he had great difficulty in talking, but understood what was 
 said, knew what he wanted. 
 
 For two or three months he continued his work, but was very in- 
 efficient and was discharged; he was not drinking as it made him very 
 nervous, nor smoking as he could not hold a cigar in his mouth. During 
 the next two years he had occasional positions, but was usually dis- 
 charged ; he was unable to add up simple bills. 
 
 He continued to spend all his money on horses, none on his wife and 
 children ; he once came back from a position much excited, said that he 
 had nearly made a million, that he received tips direct from God; he 
 frequently made the latter assertion. 
 
 His domestic behavior became more outrageous and indecent; he occa- 
 sionally left his wife; he would make silly remarks, e. g., tell his wife 
 to dress up in gauze and waltz round. Although limping badly and stag- 
 gering so that he seemed about to fall, he maintained that he was all 
 right. 
 
 In 1903 he gradually became completely deaf in both ears. Owing to 
 his dilapidated behavior he was finally certified as insane. 
 
 During the eighteen months spent in the hospital the patient has 
 shown no change. According to his wife he was always an accom- 
 plished liar, and in hospital the patient tells a plausible story, admitting 
 his alcoholic and gambling propensities, but denying that he ever talked of 
 receiving tips from God, that he talked of making a million or that 
 he ever behaved outrageously. He gives a good chronological account 
 of his life with exact dates and no discrepancies. He converses 
 rationally (the physician has to write his questions), takes an interest in 
 the daily papers, remembers incidents well, has a fair grasp of current 
 events, and ordinary information ; he adds promptly, calculates the equiva- 
 lent in British coinage of $385 with only a slight mistake.
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 55 
 
 Physically, he is a well-built man, 48 years of age, with exaggeration 
 of all the deep reflexes and residuals of the left-sided hemiplegia attack 
 in 1901 — weakness of the left side, left-sided ankle clonus, double Babinski, 
 no dulling of sensibility on the left side. In addition to the mowing gait 
 of the hemiplegic he is markedly ataxic; closing the eyes increases his 
 unsteadiness in the upright position. The pupils are unequal, irregular; 
 the right is Argyll Robertson, the left reacts rather sluggishly to light. 
 The speech is loud and slurring, but not sticking nor tremulous. His 
 writing is on the whole good, but there is occasional untidiness, omission 
 and repetition of a word or letter or mistake with a syllable, e. g., 
 Epis/'ocal, charterwz^, resigcnd, practi//3>. He cannot name the test solu- 
 tions, but smells equally well on the two sides. He occasionally hears a 
 very loud command ; he hears several noises on the ward. There is a 
 well-marked lymphocytosis of the cerebrospinal fluid. 
 
 In this case, as in the first, the development of the disease was masked 
 by alcoholism, and the patient still has the attitude of a plausible alcoholic 
 liar. This somewhat complicates the estimation of his insight. He wishes 
 to go out, says that he wishes to work for his wife, and that old 
 employers may help him to get some position. While he recognizes his 
 deafness and the presence of weakness on the left side, he does not 
 admit any mental impairment nor have an adequate idea of his physical 
 condition; his wife had been struck by his refusal to admit that there 
 was anything the matter with him. 
 
 The patient's marked alcoholism accounts in part for his abnormal 
 behavior before admission, but not for several factors — ^the absolute loss 
 of the sense of decency (the patient would defecate on a chair instead 
 of going to the toilet; he would, when apparently sober, sexually assault 
 his wife in presence of the children), the childish behavior (e. g., he 
 would throw into the box a letter with a farewell message to his wife, 
 and would then run away), his receiving tips from God and talk of 
 making millions (at this time he was not drinking hard). This behavior 
 had a peculiar stamp of dilapidation ; it is met with in general paralysis, 
 and I do not know if cases of brain syphilis may present it. 
 
 Mentally, then, the important differential points in this case are 
 the special form of dilapidated conduct, the inadequate realization 
 of his condition, the psychotic symptoms, and the mistakes in 
 writing. The condition of the pupils may be met with in brain 
 syphilis; as to the value of the ataxia with definite sign of Rom- 
 berg as a differential point between general paralysis and the vari- 
 ous forms of brain syphilis, I have no data. 
 
 Case 5.— Joseph W. G., 38, admitted July 30, 1901. 
 
 The patient was born in 1864 in New York city, developed normally 
 and worked at a variety of occupations; he is not known to have taken 
 alcohol to excess. In 1890 he had a sore on his penis, and took internal
 
 56 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 medicine for one month; in 1894 he began to suffer from pains in the 
 back and chest, accompanied by nausea and vomiting; for the next six 
 years he continued to have episodes of lancinating pains at intervals of 
 two and three weeks ; in 1900 he was diagnosed incipient locomotor ataxia ; 
 the pupils were Argyll Robertson, the knee jerks diminished. 
 
 For a few months before commitment in 1901, he had grandiose plans 
 for working a patent, he talked a great deal about money, and, when 
 committed, he was talkative, elated, and expansive; he said that he was 
 worth $90,000, the patent was worth $35,000,000. 
 
 After a few months, this trend simmered down and the patient became 
 slightly depressed ; one year after admission, he had much improved and 
 possessed considerable insight into his past condition. 
 
 He had later a depressed period, then in 1904 was megalomanic. 
 
 Neurological Incidents. — The patient had already in 1898 had a transi- 
 tory weakness of his left side with paraesthesia, of half an hour's dura- 
 tion; in 1903, he had an attack of unconsciousness followed by con- 
 fusion; in 1904 he had a sudden apoplectiform attack, leaving a perma- 
 nent left-sided hemiplegia with marked impairment of sensibility on the 
 left side, and with left-sided hemianopia. 
 
 Present Condition, November, 1906. — The patient has, for at least a 
 year, shown practically the same condition ; he is quite clear, knows all 
 the hospital gossip, takes an interest in the papers, wishes to go home; he 
 admits that he had temporary insanity on admission, sometimes he says 
 that it was the commitment which made him insane; he says that he was 
 funny, had strange ideas in 1901 ; he attributes his megalomanic attack in 
 1904 to being tormented by other patients. He misinterprets various 
 paraesthesias as due to electricity and magnetism, and frequently shouts 
 out loudly at night owing to this torment ; when questioned on the 
 subject, he is evasive, at first merely talks of an uncomfortable mattress, 
 then admits that the feelings must be due to electricity, etc. ; there is 
 little attempt to elaborate the subject. He says that he is constipated; 
 when urged, he makes hypochondriacal statements as to his abdomen, his 
 stomach is all cut out, he is ruined, he is only a shell, the attendants 
 during his crazy spell in 1904 cut his stomach out with poison. 
 
 The patient has an excellent memory, both for the recent and the 
 remote past, he has a detailed grasp of his various transfers in the hospital 
 and of the dates of minor events ; there is no discrepancy in his dates. 
 
 Physically, the patient shows the residuals of a left-sided hemiplegia; 
 there is little weakness, but there is Babinski reflex on the left side, 
 hemiplegic gait with the arm in the wing position, the sensibility much 
 more impaired on the left than on the right side; left-sided hemianopia; 
 there is marked ataxia of left arm and leg; the difficulty in maintaining 
 the upright position is not increased on closing the eyes; the knee jerks, 
 which were diminished in 1901, are now definitely exaggerated; the 
 pupils are equal, irregular, Argyll Robertson. Writing tremulous with 
 distorted words. Speech tremulous. 
 
 The patient realizes his physical impairment, he attributes it to his
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 5/ 
 
 treatment in the hospital, misinterprets his abnormal sensations; he is 
 anxious to go home and help his mother, says that he can get a job as 
 night-watchman, in some places the watchman needs only to sit behind 
 the door all night, he could make money as an entertainer as he is full 
 of jokes, he could write a book of experiences, and would easily find a 
 publisher. 
 
 This self-confidence is based rather on a want of judgment of the 
 ordinary relations of life than on a failure to recognize his own general 
 condition; it is the same symptom, though in less degree, as his original 
 grandiose plans to develop a patent. 
 
 He admits that he is physically weak and that he is even slightly 
 touched in the head; fresh air and city doctors will soon cure him. 
 
 The patient's want of judgment is seen in another point; he fre- 
 quently sits and loudly talks of the injustice of his detention; when 
 interviewed, he frequently repeats his grievances, but he does so more 
 apparently to give vent to his feelings than with any hope of changing 
 the situation. 
 
 He never argues the point with the physician, never asks him to take 
 definite steps for his discharge nor asks him for the grounds of his 
 detention; while repeating his claims, he acquiesces in the situation, some- 
 times even laughs at it and bears no ill-will for his detention. 
 
 This acquiescence in the situation in certain cases of dementia para- 
 lytica contrasts strikingly with the retained intellectual grasp of relations 
 and with the actual demands for discharge, which may be set aside by 
 the physician without provoking any rerhonstrance from the patient. Be- 
 sides these defect symptoms the patient has presented additional symptoms, 
 megalomanic periods, persistent hypochondriacal statements, and false 
 interpretations of morbid sensations. The importance of the former two 
 elements in the diagnosis of general paralysis is generally emphasized: 
 one must remember, however, that in syphilitic meningoencephalitis a 
 megalomanic trend may be present, and a hypochondriacal element is 
 frequently present in arteriosclerotic dementia.* 
 
 Case 6. — Mrs. Annie F., 43, admitted March 18, 1905. 
 
 The patient is a Russian woman of low social status, who was an 
 efficient housewife, and enjoyed moderate health until igo2 or 1903; no 
 history of syphilitic infection was obtained from the informants, but the 
 patient had numerous suspicious scars on her legs; she had several mis- 
 carriages and her husband has suspicious nervous symptoms. About 
 three years before admission, she began to eat ravenously and to sleep 
 constantly, she neglected her housework, was very apathetic, complained 
 of frontal headache and of seeing double. On one occasion, about two 
 
 *The patient died on May 28, 191 1 from a sub-dural haemorrhage 
 caused by a fall during a convulsive seizure. At the autopsy the brain 
 presented a diffuse atrophy of the right hemisphere, but no definite evi- 
 dence of general paralysis: microscopical examination disclosed the histo- 
 pathological changes of general paralysis.
 
 58 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 years before admission, she daefecated in bed, then threw the faeces with 
 her hand on the wall; when asked what was the matter, she said 
 "nothing"; during the last two years, she spent the whole time sitting 
 in her chair, took no interest in what went on, admitted that she was 
 weak, but said that there was nothing wrong with her; she answered 
 most questions with " I don't know," she occasionally soiled the bed. 
 There was no history of elation nor depression ; a vague statement that 
 she had heard voices was not corroborated. 
 
 On admission the patient was very placid, had a never-failing me- 
 chanical smile; she answered questions pleasantly, but showed little spon- 
 taneity; her mood was one of complacent indifference; she accepted the 
 environment without criticism; there was no elation, no definite de- 
 pression, but she felt that she was an invalid, emphasized her ailments 
 with some hypochondriacal zest ; " I am very weak — I am nearly blind — I 
 can't walk." She gave a strong handgrip; her gait was shuffling, but not 
 very much impaired; she could count correctly fingers held up at ten 
 feet ; at the same time she said that she saw double. 
 
 The patient showed a marked memory defect, which consisted not so 
 much in loss of memory of the incidents as in inability to space them 
 out correctly in time; successive answers to the same questions were 
 widely different, e. g., she said that she sailed for America at 15, 19 and 
 29; with regard to other events, she gave equally inconsistent dates. 
 She did not spontaneously see even glaring discrepancies ; she said that 
 she was divorced at 23, came to America at 25, came to America in 
 the year of her divorce. She was an extremely ignorant woman, but 
 her calculation was better than one would have expected. 
 
 The patient realized her changed mental and physical condition ; " I 
 am not clear — I have not the spirit of work — I should like to sleep always 
 for the last two years — my head is so slow — my head is weak " ; she 
 exaggerated rather than minimized her physical ailments. 
 
 Physically, she was a well-nourished Jewess with fair muscular 
 force and no sensory disorder; the knee-jerks were both exaggerated; the 
 gait was shuffling, not ataxic ; sign of Romberg was noted on the first 
 examination, but not on subsequent examinations ; there was tremor and 
 jerking of individual fingers; the speech showed decided sticking on 1 
 and r with tremor of the facial muscles ; the pupils were equal, reacted 
 well ; weakness of left external rectus and slight nystagmus in external 
 fixation. She complained of a variety of subjective disorders during the 
 previous two years — severe frontal headaches, noises of whistling and 
 ringing in the ears, her head felt funny, she was like drunk, was dizzy. 
 
 During the nineteen months of hospital residence, the patient has 
 shown little variation ; she does whatever work she is asked to do, keeps 
 track of the time and of the major incidents in the ward; during an 
 interview she asks for discharge, but never pushes the question nor 
 spontaneously addresses the physician with this in view. 
 
 In this case, as in the preceding cases, there was a dementia
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 59 
 
 characterized by an inadequate attitude towards detention and by 
 a striking inability to see glaring discrepancies in dates ; additional 
 features were the episode at the onset and the mild hypochon- 
 driasis. 
 
 I do not know that cases of brain syphilis ever present such a 
 form of dementia. 
 
 Tabes and General Paralysis. — Where a psychosis is found to 
 be associated with tabes one is tempted to immediately conclude 
 that the case is one of general paralysis. In several cases reported 
 in the literature, where this was not done and a non-paralytic 
 dementia with tabes had been diagnosed, the anatomical examina- 
 tion demonstrated the histopathological changes of general paral- 
 ysis. Many cases have been published of non-paralytic psychoses 
 with tabes ; there is on the one side the case where a patient with 
 a psychosis, e. g., a manic-depressive, gets syphilis and later de- 
 velops tabes, and, on the other side, the case where on the basis 
 of an established tabes a psychosis, usually a paranoic condition 
 or a depression, arises. 
 
 Alzheimer records two cases where the dementia was demon- 
 strated to be not due to a general paralytic process. 
 
 In the following case, for a long period it was felt that there 
 were insufficient grounds for considering the disorder general 
 paralysis ; the nature of the dementia which later became estab- 
 lished cleared up the diagnosis. 
 
 Case 7. — Mary B., 46, admitted February 22, 1905, discharged De- 
 cember 24, 1905; readmitted May S, 1906. 
 
 The patient is an Irish woman who has lived a rather irregular sexual 
 life, and whose husband claims that he received syphilis from her in 1899; 
 there is no history of alcoholism. On the death of her youngest child 
 in October, 1904, she was rather depressed, but seemed to regain her equi- 
 librium. In February, 1905, she began to complain of being sick and of 
 pains in her legs ; she was sleepless, refused food and medicine. Two 
 weeks later she made peculiar treading movements with her legs in bed, 
 said she could not help it. 
 
 For several days before admission she said " I think I'm getting 
 crazy." She told the ambulance surgeon that worry over her baby had 
 driven her crazy. In Bellevue Hospital she uttered ideas of fear with 
 smiling unconcern ; she said " I see all kinds of funny things when I 
 close my eyes, I'm so light-headed all the time, I hear kind of funny 
 noises in my ears." 
 
 On admission the patient was quiet, seemed to take no interest in her
 
 60 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 surroundings, showed no spontaneity; she answered questions in mono- 
 syllables, replied " I don't know " to almost every question, even to ques- 
 tions to which she had previously given a correct answer. Her mood, 
 when unmolested', was one of complete indifference, but when examined 
 vigorously her unconcern was replaced by a look of dazed perplexity 
 and some alarm and agitation. Owing to her monotonous answer of 
 " I don't know," or " I can't tell " to almost every question, her memory, 
 grasp of general information, etc., could not be tested. 
 
 Physical Status. — Absence of knee- and Achilles-jerks, also of corneal 
 and pharyngeal reflexes; very slight reaction of pupils to light, fair on 
 accommodation ; unsteadiness of gait and upright position ; no reaction 
 to pin-pricks except over the soles of the feet. The mouth was foul, the 
 tongue dry and hard. 
 
 For two or three weeks the patient continued to give the same nega- 
 tive answers; she made no sign of recognizing her children. She said 
 that she was blind, but at the same time she recognized figures and 
 letters. One day she said that she had no feeling, no life — "you have no 
 idea how terrible I feel, I wish I was dead rather than in this way." On 
 one occasion she recognized her children at first, but during the same 
 interview said that she did not know them; when asked to explain this 
 she said, " I could not see them — I could not see them plain." 
 
 In April she improved, took some interest in home affairs, was more 
 cleanly; for two weeks she frequently walked with her legs crossed, even 
 when going up-stairs; no reason was given for this. She winced at pin- 
 pricks, but denied that she felt pain. She began to answer questions about 
 the past, but was absolutely indifferent to absurd contradictions in her 
 time relations; she remembered in remarkable detail the events associated 
 with her admission, having registered correctly even the names of the 
 patients who came with her from Bellevue Hospital to M. S. H. ; for a 
 while she was depressed over her condition, which she described as in- 
 curable insanity. Although she had a fair grasp of the environment, she 
 thought the city was " empty houses," the people on the passing steam- 
 boats were " make-believe." 
 
 Her memory improved so that she was able to give a fairly accurate 
 account of her life. In December she was well enough to be discharged. 
 Her plans for the future were quite reasonable; she had good insight into 
 her mental disorder, remembered the various peculiar ideas she had had. 
 Physically there was noted absence of knee-jerks, Argyll Robertson pupils, 
 slight difficulty in speaking the test phrases; no tremor, no ataxia, no 
 sign of Romberg. 
 
 In view of the close connection of tabes and general paralysis the 
 diagnosis of general paralysis seemed the most probable one, but in view 
 of the peculiar nature of the mental symptoms the diagnosis was not 
 considered as established, nor the possibility of a non-paralytic tabetic 
 psychosis excluded. The mental picture had been that of a depression, 
 with a consciousness of mental inefficiency, which later passed into a 
 peculiar condition of apathy with negative replies ; when she improved
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 6 1 
 
 SO far as to give her history, she ignored the hopeless discrepancies in 
 her statements; on further improvement her discrepancies seemed almost 
 sufficiently accounted for by her general ignorance. The possibility of an 
 hysterical element was suggested by the apparently blank state of mind, 
 the abrupt alternation between recognition and non-recognition of visitors, 
 the denial of any memory of a visit with no indication of an actual defect 
 of retention, a certain suggestibility, and the peculiar gait which seemed 
 to arise from a casual attitude ; the pharyngeal reflex was absent, the 
 corneal much diminished, there was almost general analgesia. 
 
 The diagnosis was therefore not considered to be established. 
 
 The patient was discharged on Christmas Eve, 1905, and appeared 
 to be in good mental health, but after about one month she began to show 
 marked lapses in conduct; she would go about the house practically naked, 
 she wandered away from home for days at a time; she was, therefore, 
 readmitted May 5, 1906. 
 
 On re-admission the patient recognized all her old acquaintances, said 
 that she was glad to be back, talked of her sickness with cheerful in- 
 difference, gossiped pleasantly about the past. She described in a matter- 
 of-fact way an episode when she had rambled away from home and spent 
 two days in the park : " I don't know why I stayed-^I guess I was too 
 lazy to walk home." She compared herself jocularly to an actor out of 
 work. She admitted that this was crazy behavior, saying " sure, I was 
 off my trolley again," but again said that she was not crazy. 
 
 She had a good memory for the incidents of the past, but showed 
 absolute inability to grasp glaring discrepancies in her dates ; she said 
 "this is 1896," and that she had her last baby July 4, 1896. 
 
 Her conduct in the ward was rather dilapidated; she was very un- 
 cleanly, at night pulled at the other patients' clothes as she wanted to 
 go home ; she pinned bed lineni under her own clothes. The garrulous 
 talk of the patient was of a drifting flighty character, e. g., " Do you 
 know my sister Nellie is dead, God is slow but he's sure, we all have to 
 go some day, how is it the Chinese get something to eat in the coffin, they 
 wake up and have something to eat (laughs), the Jews put in a quarter, 
 she was buried in Evergreen with her husband," etc. 
 
 She commented on passing boats and on remarks of other patients. 
 
 Her writing was much worse than during the previous admission, the 
 words being distorted into a series of meaningless characters. 
 
 After about a month the patient had given up her pranks, was cleanly 
 and a useful worker, and since that time she has continued to maintain 
 the same level of a mild dementia. She knows all the hospital gossip, 
 enjoys life in the ward but talks of returning home again ; her future 
 plans are quite reasonable. She still shows absurd discrepancies in her 
 dates, e. g., married in 1885, born in 1896. She admits that she was 
 crazy on her first admission, but not on the second; she was only brought 
 here because she went to the park. 
 
 The following are the important features in her dementia — the
 
 62 THE DIAGNOSIS OF GENERAL PARALYSIS 
 
 contentment with hospital life as satisfying most of her aspi- 
 rations, the imcritical attitude towards the wandering episodes and 
 past behavior, the absurdly contradictory dates, the extreme dis- 
 tortion of written words ; such a dementia presents the features 
 which in the preceding cases were emphasized as of differential 
 importance, and in conjunction with tabes warrants the diagnosis 
 of dementia paralytica. 
 
 From the above observations it would seem that for clinical 
 differentiation a study of the dementia itself is important. The 
 dementia, however, was not the only element present in the cases ; 
 other features were also present, either behavior with a peculiar 
 stamp of dilapidation, or psychotic symptoms, which form the 
 " crazy " element in the picture. 
 
 The limits of this communication do not permit a discussion of 
 these latter symptoms, but it is sometimes on these latter symp- 
 toms that our diagnosis frequently rests ; the diagnosis may be 
 established before the presence of any dementia can be demon- 
 strated ; no defect may be observed save the absence of the pa- 
 tient's critical faculty in face of his own grandiose plans. 
 
 This was the case in the following observation. 
 
 Case 8.— The patient (Emil K.), admitted January 13, 1906, age 35, 
 an alcoholic bartender, became restless and irritable shortly before ad- 
 mission, was unable to do his work, formed great plans for making money, 
 was sent to the hospital. When admitted to the hospital he was restless, 
 excited, talkative, harped on his grandiose schemes : he intended to marry 
 a beautiful girl, would call on the Emperor, etc. He showed absolutely 
 no memory defect, was clear in his orientation. His restlessness quickly 
 disappeared, the expansive trend simmered down, and two months after 
 admission there was no trace of the psychosis, except a slight tendency 
 to minimize the absurdity of his crazy ideas on admission. 
 
 He was discharged four months after admission apparently in excellent 
 mental health, took up a position and earned fair wages. 
 
 His physical status presented the same neurological complex during 
 his whole stay in the hospital — exaggeration of deep reflexes, unequal 
 pupils reacting sluggishly to light, tremor of fingers and tongue, marked 
 lymphocytosis of the cerebrospinal fluid; no defect in speech, writing nor 
 gait. 
 
 Here, then, was a fairly pure megalomanic episode without any of the 
 defect symptoms described above. The diag^nosis, however, did not 
 seem open to doubt. 
 
 In such a case the presence of a well marked lymphocytosis is a 
 source of comfort to the clinical observer.
 
 THE DIAGNOSIS OF GENERAL PARALYSIS 63 
 
 The last case which I wish to report is that of a patient observed 
 by Dr. Meyer, where the possibiHty of brain tumor was seriously 
 considered, but which turned out to be an atypical general 
 paralysis. 
 
 Case 9. — The patient was born in 1857, at the age of 23 had some 
 venereal infection, when 42 complained of unsteadiness and weakness of 
 the left hand ; he became fatigued, unable to do his work ; his gait 
 became unsteady, with weakness of the left leg. After three months' 
 vacation he became slightly expansive, irritable, and showed a childish 
 behavior. 
 
 January 17, 1900, twitching of the left arm, anesthesia of the left arm, 
 reduction of muscular sense and attention to motility on the left side, 
 exaggerated tendon reflexes on the left side. The anaesthesia spread 
 later to the trunk and the left leg; Babinski reflex developed on the left 
 side. In October the patient had an attack of left-sided twitching; after 
 this, left-sided hemianopia was noted. The left pupil was larger and 
 more sluggish than the right. The left side became more rigid. 
 
 As to the mental symptoms the patient had been euphoric and talka- 
 tive at first, with good orientation, fair memory, but defective calculation. 
 In summer he became dull, careless and untidy. In November he fabri- 
 cated; he later became duller and less responsive. He died May, 1901. 
 
 As to the diagnosis, the optic discs were normal, there was no history 
 of headache, vomiting nor dizziness, but both the irritative and the para- 
 lytic symptoms with their steady progression suggested the possibility of a 
 tumor. The mental symptoms suggested strongly general paralysis, but 
 were not inconsistent with brain tumor. 
 
 On post-mortem examination it was found to be a case of atypical 
 general paralysis, the process being of exceptional severity over the 
 posterior half of the right hemisphere. In some parts of this region 
 there was complete disappearance of the nerve cells; the vessel changes 
 were well marked, the perivascular infiltrate moderate. On the right 
 side the pulvinar was much affected. In addition to the severe affection 
 of the right parietal and occipital lobes there was present a correspond- 
 ing atrophy of the left cerebellar hemisphere.
 
 CLINICAL VARIETIES OF PERIODIC DRINKING^ 
 By Pearce Bailey, M.D., 
 
 NEW YORK 
 
 Singled out and separate from habitual drinking is a type of 
 alcoholism characterized by its periodicity. There are recurring 
 attacks of intemperance and debauch, lasting from a few days to 
 several weeks. Between the attacks the subjects are either tem- 
 perate or abstemious, or have a distinct distaste for liquor, and, 
 for the first few years at least, bear none of the physical or mental 
 stigmata of alcoholism. The periodic character of this variety of 
 inebriety has long caused it to be compared with another par- 
 oxysmal disease, epilepsy. And since Gaupp, in a carefully pre- 
 pared monograph on dipsomania, published in i9oi,drew the lines 
 closely together from cases of his own and from literature, there 
 has been a gradually growing conviction that dipsomania is one 
 of the larval forms of epilepsy. It cannot be denied that there 
 are striking points of similarity between typical cases of dipso- 
 mania and epilepsy. Many dipsomaniacs have had convulsions 
 and in nearly all of them may be found the same neuropathic 
 antecedents as are met with in the histories of epileptics. Again, 
 the action of alcohol upon a diseased or intolerant brain recalls 
 in many ways certain symptoms of epilepsy. Intolerance to alco- 
 hol, to the results of which the Germans have given the name 
 pathological drunkenness, is essentially epileptic in character. In 
 it, after the ingestion of very small quantities of spirits or even 
 beer, the individual becomes immediately flushed and excited, vio- 
 lent and often dangerous to others. A similar intolerance is com- 
 mon in epileptics, and is particularly liable to induce states of 
 automatism in which the patient is no longer responsible. It is 
 also frequent in other cortical diseases or degenerations, of which 
 it may be the earliest diagnostic sign. Notable among the brain 
 
 ^ Read at a meeting of the New York Psychiatrical Society on May 5, 
 1909. Copyright, William Wood & Company. 
 
 6 65
 
 66 CLINICAL VARIETIES OF PERIODIC DRINKING 
 
 conditions in which intolerance is encountered are general paresis, 
 degeneration of the cerebral arteries, and the state of depressed 
 cortical function which often follows traumatic injuries of the 
 head. 
 
 In addition to these general similarities an attack of dipso- 
 mania has certain psychic characteristics in common with those of 
 grand mal. In both the patient becomes, for a short time before 
 the attack, restless, anxious, dissatisfied ; he reproaches himself 
 for misconduct which had long lain forgotten ; and all this without 
 reasonable cause. This premonitory depression is constant in 
 true dipsomania and is becoming more and more recognized as a 
 cardinal symptom of epilepsy. In addition, retrograde amnesia, 
 as well as amnesia for parts of the attack itself, is common in 
 both conditions. 
 
 I have notes of a case of a young man, by nature temperate and 
 self -controlled, in whom the attacks recurred every two or three 
 months, sometimes less frequently. The antecedent depression 
 was marked, and readily recognized by the family. The seizures 
 were characterized by wild intemperance, debauch, and violence. 
 There were distinct losses of memory for parts of the attack itself, 
 and often also for several hours preceding the first drink. The 
 apparently hopeless outlook in this case, which I have watched 
 for five years ; its explosive character without any psychic cause 
 which can be ascertained, and the bad family history, seem to 
 mark it definitely as dipsomania of epileptic nature, dependent on 
 the same cortical irritation as causes epilepsy. Certain cases cited 
 by Gaupp also seem equally incontestable. But such cases are 
 rarities. 
 
 Perhaps no one sees so many varieties of alcoholism in their 
 formation period as a neurologist practising in a large city. And 
 of the various cases of periodic drinking I have seen, the one men- 
 tioned is the only one in which epilepsy seemed the only explana- 
 tion. In the others, various causal factors pressed forward for 
 recognition, equally or more deserving of attention than epilepsy. 
 So I now believe that many of the so-called epileptic dipsomanias 
 can be better explained on some other hypothesis ; that what seem 
 at first sight as epileptic explosions can frequently be reduced to 
 certain phases of mental disease, the clinical characteristics of
 
 CLINICAL VARIETIES OF PERIODIC DRINKING 6/ 
 
 which soon become blurred by alcohol, or to the influence of some 
 recurring psychic motive. 
 
 The importance of such a distinction is real, both for prognosis 
 and treatment. True dipsomania has the same prognosis and 
 treatment as epilepsy. Periodic drinking from other causes offers 
 more hope for amelioration in that the cause, when found, is 
 more get-at-able ; and the case as a whole can be better understood 
 and more rationally handled, if its causal factors are revealed. 
 
 In the listed types of mental disease, alcohol plays a varying 
 role. It is not conspicuous in dementia praecox or in melancholia. 
 In fact, the generally received belief that mental depression causes 
 periodic drinking seems true only insofar as it applies to depres- 
 sion within the limits of sanity. Under the stress of business 
 reverses, family troubles, failing health, many become tipplers. 
 Some become periodic drinkers. The most familiar type of this 
 is the emotional, high strung man who gets wildly drunk, often 
 for several days, after quarrels with his wife. But the recurring 
 attacks of depression in which the depression is out of sane pro- 
 portion to the causes alleged to have induced it — that is, the 
 recurring depressive cycles of a manic-depressive insanity, seem 
 rarely if ever to incite to inebriety. 
 
 In general paresis sudden attacks of inebriety are extremely 
 common, as is to be expected from the epileptic associations of 
 this disease. It is only when these attacks precede the physical 
 signs or the mental deterioration that diagnosis is difficult. 
 
 In the manic phases of a manic-depressive psychosis, periodic 
 drinking occurs in a way to obscure the clinical picture. In these 
 cases the mental disease is accountable for the inebriety ; but the 
 effects of alcohol so far change the ordinary clinical behavior that 
 it is usually only after two or three attacks that the true nature 
 of inebriety is discovered. The two following cases illustrate this : 
 
 One is that of a young man who has been committed to Bloom- 
 ingdale thirteen times in the past ten years. I appeared in one 
 commitment, but for details of the history I am indebted to Dr. 
 S. B. Lyon. The original diagnosis was dipsomania, and the 
 patient's wife still believes alcohol to be at the root of all the 
 trouble. In the beginning of the attacks while drinking, he is 
 confused, delusional, and disordered, with more or less excite- 
 ment. During the attacks, he is abusive, denounces his commit-
 
 68 CLINICAL VARIETIES OF PERIODIC DRINKING 
 
 ment as unjust, and threatens court proceedings. Before some 
 of the commitments, he has been violent and made assaults. On 
 one occasion he improved sufficiently to be removed by his mother. 
 Two days later, he was drunk again with return of mental symp- 
 toms — he was dirty, disheveled, excited, garrulous, talked rapidly, 
 profanely, and disconnectedly — a condition lasting several months. 
 Another case of this character is the following: 
 A man, 37 years of age when he first came under observation, 
 had proved himself of more than ordinary business capacity. He 
 had built up a successful business and had made shrewd invest- 
 ments. At college he had been regarded as intemperate. He 
 used to go off on sprees, though not a regular drinker, and acted 
 queerly. He was married in 1904, the bride being aware of his 
 reputation. Shortly after his marriage, he refused for a time to 
 speak to his wife, felt that he had lost all his money, felt that there 
 was no hope for him, and threatened suicide. During this time 
 he did not drink at all. In August, 1905, he began to drink and 
 was intoxicated most of the time. At the same time, he became 
 expansive. He bought a great many things that he had no use 
 for, though he almost always got good bargains. A piece of real 
 estate that he bought at this time was sold at double the price he 
 paid for it. He would play the piano all night and would go out 
 in his night clothes at four o'clock in the morning to feed the 
 dogs and chickens. He kept the whole house awake with his 
 orgies, drinking constantly ; he would lock himself in the wine 
 closet for hours at a time. Though very drunk, he appreciated 
 fully the object of a visit from two examiners in lunacy and 
 swore he would not be locked up. Placed in confinement, the evi- 
 dences of alcoholism rapidly left him and he remained in a con- 
 dition of mild reasoning mania. He reasoned with such skill 
 that no sheriff's jury would have held him, and as he insisted on 
 liberty or an inqnirendo^ he was discharged. He immediately 
 became much depressed, bore no ill will toward those active in 
 his commitment and did not drink at all. Later he resumed drink- 
 ing wine at dinner without apparent ill effect and without intem- 
 perance. For three years he was well, temperate, successfully 
 engaged in business. There was one period of excitement and 
 intemperance which lasted several weeks, but for which no special 
 medical attention was necessary. In the autumn of 1908 he
 
 CLINICAL VARIETIES OF PERIODIC DRINKING 69 
 
 began to drink again. He would insist on making several cock- 
 tails for everyone who called ; he wrapped a napkin about his 
 waist, served all drinks himself and said he was the butler. And, 
 as before, would lock himself in the wine closet for hours. He 
 developed persecutory ideas. Thought that detectives were after 
 him, that the people on the street were making remarks about 
 him, that people in neighboring houses were mocking him. He 
 was placed, without commitment, in a private sanatorium. He 
 thought he was committed and would not cross the threshold of 
 his room in the fear that the police would get him. He had devel- 
 oped some important signs of alcoholism. The knee jerks were 
 absent. And another sign, the occurrence of which as an alco- 
 holic symptom is overlooked in most text-books, was that the 
 pupils did not respond to light. After a few weeks' abstinence, 
 both the knee jerks and the light reflex became normal. But he 
 still was insane and was committed. 
 
 He was filthy in his habits and would spend his days making 
 messes of food and odd bits of rubbish, which he called inven- 
 tions. He was confined altogether for about two months, at the 
 end of which time he was well enough to be discharged. He again 
 became depressed, all delusions left him, and he had no desire 
 to drink. 
 
 Both of the above cases seem to have classed themselves pretty 
 definitely as manic phases of manic-depressive insanity. By some 
 peculiarity of personal disposition or environment the expansive 
 periods announced themselves by sudden outbursts of inebriety; 
 and the resulting alcoholism marred the clearness of the mental 
 picture. But the diagnosis was long in doubt, and by the lay 
 mind both patients still are believed to be periodic drinkers. 
 
 Outside the sphere of well defined psychoses are many mental 
 states touching the abnormal and characterized by instability, by 
 impulsiveness, by excessive psychomotor reactions. It seems rea- 
 sonable to think that further examination in this field may throw 
 much light on periodic drinking. 
 
 Many of the psychic causes and the psychic effects of alcohol 
 are interchangeable. In studying the mental states which lead to 
 drinking, we may find one that seems important, and mark it down 
 as an essential cause. Then, later, when observing the effects on 
 character of alcoholism, we come again, with startling frequency,
 
 70 CLINICAL VARIETIES OF PERIODIC DRINKING 
 
 upon the same feature which caught our eye when studying causes. 
 It may have become, perhaps, discolored, and present lines more 
 sinister, but is none the less unmistakably the same as we knew 
 it as a cause. Take, for example, fear. Fear as a cause of drink- 
 ing has become a proverb, and so requires neither exploitation nor 
 comment. As a symptom, fear is disseminated through the whole 
 clinical fabric, from the timidity of the besotted vagabond to the 
 wild terror of the victim of alcoholic hallucinations. Thus fear 
 is both a cause and an effect. So it is with many other of the 
 factors busy in the genesis of this world disease. We see them 
 as causes and, shortly afterwards, they are looking at us branded 
 as effects. Like sheep at pasture, they jump their boundaries. 
 
 Sexual desires, wrong moral attitudes, idleness, jealousy, all 
 appear indifferently in the category of causes or effects. And 
 in studying the springs of inebriety, we may do worse than 
 begin with the effects. Two of these latter — sexual excitement 
 and jealousy — deserve especial scrutiny. The relationship which 
 exists between the sexual appetite and the stimulant which best 
 arouses it needs only to be mentioned to be recognized. Indis- 
 criminate license, sexual perversion, sexual crimes, all are the 
 results of intoxication, as readily appears in every treatise on 
 psychiatry and legal medicine. But that certain forms of alco- 
 holism owe their existence to sexual desire is not so well estab- 
 lished. Normal intercourse has nothing to do with drinking; 
 and the alcoholic hilarity which enhances the popularity of the 
 brothel stimulates desire rather than results from it. But in 
 periodic drinking, the generative feature stands out more closely. 
 Procreative tendencies are themselves more or less periodic in 
 their appearances ; and their impulsive character is revealed by 
 such degenerates as exhibitionists and curl cutters or by such im- 
 perative ideas as are found in the psychoses which result from 
 sexual traumata in childhood. I have yet to meet a periodic 
 drinker who was not an erotomaniac as well. One patient 
 whom I have observed for fifteen years and who has been in- 
 carcerated in almost every institution within lOO miles of New 
 York has never gone on a spree from which harlots were ex- 
 cluded. With him, contemporaneously with the idea of the initial 
 drink, came the idea of sexual gratification. And when his 
 family went to look him up, they would always find him in a
 
 CLINICAL VARIETIES OF PERIODIC DRINKING ^l 
 
 house of prostitution, never in a bar-room. It is true that in 
 many dipsomaniacs, the erotic ideas do not make their appear- 
 ance until the stimulant has aroused desire. But in the case just 
 described they appeared as soon as, if not sooner than, the im- 
 pulse to drink; and there would be no difficulty in mustering 
 other cases of this class. So it seems worth while to give at- 
 tention to the hypothesis that some cases of dipsomania arise 
 in the sexual centers rather than in the motor cortex — and that 
 they are a part of a general neuropathic state and are psycho- 
 genic in origin, having no direct relationship to epilepsy. Cases 
 in this class distinguish themselves from epileptic dipsomania 
 in that aggressive physical violence is not conspicuous during the 
 attacks ; that the attacks can persist over many years without pro- 
 nounced mental deterioration ; and that, as time goes on, the 
 attacks may become less severe and less frequent. 
 
 Another variety of periodic drinking is sometimes met with 
 in personalities mildly paranoid, usually of the jealous type. 
 Jealousy is among the most frequent of the psychic symptoms of 
 chronic alcoholism, and consequently when one encounters a case 
 of alcoholism with jealous delusions one is apt to infer that the 
 delusions are toxic products. But this is not always correct. In 
 a number of cases that have come under my notice subsequent 
 events have shown that the periodic drinking was a fortuitous 
 circumstance. The paranoid state was amplified by it, but ex- 
 isted independently of it — and in one case in particular was 
 only moderately intensified by the alcohol. 
 
 This case was that of a lady of highly neurotic temperament 
 and a jealous disposition. After having borne her husband sev- 
 eral children she became infected with syphilis. The infection 
 is believed to have occurred at a gynecological operation. The 
 husband never had syphilis. But the occurrence of the misfor- 
 tune intensified the wife's jealous state of mind. She wished to 
 know everywhere her husband went ; would upbraid him for his 
 alleged attentions to other women ; and frequently insulted dif- 
 ferent female members of her own family on the ground that her 
 husband was unduly attentive to them. Her attitude toward 
 her husband was fluctuating ; at one time solicitous and affection- 
 ate, at another she would work herself up into a jealous rage, 
 upbraiding him and accusing him of all manner of improper
 
 72 CLINICAL VARIETIES OF PERIODIC DRINKING 
 
 acts of which he was guiltless. On these occasions, she would 
 take to drink, which intensified her fury. Once she developed 
 a typical jealous mania. She went to the police and set detec- 
 tives on her husband's trail ; interviewed the newspapers ; threat- 
 ened divorce ; put a truly insane interpretation on the most trivial 
 circumstances ; said she would ruin her whole family if neces- 
 sary, but that her husband should be exposed. She was drink- 
 ing heavily at this time and those who saw her — police, detec- 
 tives, and members of her own and her husband's family — all 
 thought her action the sole result of drink. 
 
 Placed under treatment and being brought to realize that none 
 of her contentions would be believed by anyone if she drank, she 
 stopped drinking, and though she stopped abruptly, showed none 
 of the physical signs of alcoholism. But the mental symptoms 
 kept on in full activity, and for months afterward, although she 
 was totally abstemious, the psychosis continued in full flower. 
 
 Another promising field for future investigation as to the 
 genesis of periodic drinking should be among the class of emo- 
 tional personalities broadly embraced by the terms hysteria and 
 psychasthenia. 
 
 Throughout the clinical range of alcoholism, both of the single 
 intoxication and of the chronic poisoning, there is disturbance 
 in the emotional sphere. Individual feelings such as anger, grief, 
 joy, fear, attain undue prominence, and react to stimuli too easily. 
 This fact explains why cures, whether they be rehgious, " scien- 
 tific," or commercial, which appeal to the emotions, are the ones 
 which have the greatest success with the drunkard. 
 
 And as we find these psychic features as results, it would not 
 be surprising if they also figured as causes. We know now 
 that many obsessions, tics, morbid fears, and even certain para- 
 noid states, had their starting points in some painful emotional 
 experience. I believe that periodic drinking, allied in many ways 
 to these psychasthenic or hysterical complexes, will soon be 
 shown, in many instances, to have had a similar starting point. 
 
 I regret that no case in my records has been analyzed from 
 this point of view, although in one case, seen many years ago, 
 there seemed an intimate connection between the paroxysms of 
 drinking and certain feelings of inadequacy, which latter resulted 
 from unfortunate surroundings in childhood. The newer metli-
 
 CLINICAL VARIETIES OF PERIODIC DRINKING 73 
 
 ods of psychoanalysis would perhaps have shown a still closer 
 relationship. 
 
 In closing, I would urge a careful psychological analysis of all 
 cases of periodic drinking. It is only by such means that the 
 proper curative measures can be unearthed. Chronic alcoholism 
 has some right and title to be considered a disease. But dip- 
 somania, in most cases at least, is not so much a disease as it is 
 disorder of personality. And the treatment must be shaped to 
 that end. Before this is possible, the defects in the personality 
 must be laid bare. The treatment, therefore, is individualistic, 
 varying in every patient in accordance with the result of the 
 analysis of him as an individual.
 
 A STUDY OF SOME CASES OF DELIRIUM 
 PRODUCED BY DRUGS^ 
 
 By Dr. August Hoch, 
 
 PSYCHIATRIC INSTITUTE, N. Y. STATE HOSPITALS 
 
 Cases of the nature of those here recorded are probably not 
 very rare. Nevertheless, during my ten years' service at the 
 M'Lean Hospital, Waverley, Mass., I have had occasion to 
 observe only eight, four of which are here presented. But it 
 seemed to me of some value to establish clearly the delirious 
 nature of these conditions, to analyse them carefully, and to 
 compare them with the deliria about which we are best informed, 
 those produced by alcohol. The excellent monograph by Bon- 
 hoeffer,^ a model of clinical analysis, has greatly advanced our 
 knowledge of delirium tremens and of deliria in general. The 
 desire was very natural, therefore, to study deliria with a dif- 
 ferent etiology in a similar manner. That the writer feels a 
 great obligation to Bonhoeffer, whose work in part guided his 
 studies and his conclusions, he desires to express at the outset. 
 
 The drugs to which these deliria were attributed are chiefly 
 bromides, hyoscine, various true hypnotics, and morphine, and 
 it is a notable fact that it seems to be of very little conse- 
 quence which drug is used ; indeed, I have seen one case in which 
 acetanilid seemed to have been the only, or at any rate, the 
 most important drug. After all, as is assumed in the case of 
 alcohol, the action of the poison introduced is probably only the 
 indirect cause ; nor does it seem to be the only one, for in- 
 sufficient food, protracted loss of sleep, digestive disorders, and 
 general exhaustion, seem to act as contributory causes. We 
 may infer this from the fact that such factors are often present, 
 and that we find occasionally conditions resembling delirious 
 reactions in manic states, for example, after just such causes have 
 
 * Read at the New York Psychiatrical Society, October 4, 1905. 
 ^ Bonhoeffer, Die Geistesstorungen der Gewohnheitstrinker, Gustav 
 Fischer, Jena, 1901. 
 
 75
 
 76 DELIRIUM PRODUCED BY DRUGS 
 
 been at work. Unfortunately it has usually been impossible to 
 determine the exact amounts of the drugs taken, and in one case 
 the doses admitted seemed too small to account for the pro- 
 found reactions. Nevertheless, the experience with all such 
 cases cannot leave any doubt regarding the importance of drugs 
 as an etiological factor in them. 
 
 Case i. — Mrs. H., aged 51. In the hospital from March 5 to March 28, 
 1903. The patient had one sister who had the opium habit. Any other 
 neuropathic traits in the family were denied. 
 
 The patient had never been insane, but since the age of 30 had com- 
 plained of very severe headaches which occurred at menstruation, and for 
 years had been in the habit of taking morphine for them to the extent of 
 % to y2 grain a day. She is said to have been perfectly well in the 
 intervals. For three months before admission the patient had not men- 
 struated, after the flow had been scanty for about a year. Two months 
 before admission the headaches again came on, and now became con- 
 tinuous ; she took morphine, rising rapidly to a grain a day, but, it is 
 said, no farther. This was continued until admission, while in the 
 meantime bromides were added. These, it was claimed, were not in 
 large doses. The patient had become irritable, and two weeks before 
 admission she began to get restless, somewhat apprehensive, and for 
 five or six days before admission she is said to have been confused and at 
 times dull. For a week she had not slept and had scarcely taken any 
 food. 
 
 On admission the patient appeared restless, evidently heard voices, but 
 she showed no fear. She was disoriented and used wrong words. At the 
 morning visit on the following day she was found with a rather pasty 
 complexion, a heavily coated tongue, a temp, of 99.2°. Her breath was 
 foul. There was no eruption on the body. There was no evidence of any 
 palsies; the movements of the arms were not ataxic, but the gait was 
 rather staggering. There was a general coarse tremor in the hands. 
 The reflexes were of normal intensity. She lay in bed tossing about 
 rather restlessly. Her mood was one of a whining depression, with some 
 irritability, but no apprehensiveness. She looked somewhat dull, and her 
 attention could at times be attracted only with marked difficulty, again 
 quite readily; but we were struck with the fact that now and then, even 
 at the time when we had difficulty in obtaining answers, she made occa- 
 sional comments on things which were said in her hearing. Hallucina- 
 tions were at times quite prominent; she had spoken of hearing bells 
 ringing, had seen pictures on the door, her sister in the pillow, a man in 
 her bed, and she tried to pick imaginary flies from the bed-clothes. She 
 was completely disoriented ; though she repeatedly called the physician 
 " doctor," the nurse " nurse," yet again she miscalled them. Paraphasic 
 turns of speech were quite marked, as we shall presently show. For the 
 two succeeding weeks her condition remained essentially unchanged, and
 
 DELIRIUM PRODUCED BY DRUGS 7/ 
 
 may be summarized as follows: Sometimes she appeared dull, even to 
 the extent of soiling herself. Her attention varied: it either could be 
 easily attracted or this was very difficult, and she could be pricked with 
 a pin without any reaction. Her disorientation remained, though shaded 
 off gradually. She thought she was in New York and other places ; 
 again, called people by wrong names. Her time orientation was very 
 poor. Sometimes she related delirious experiences; for example, said 
 that she had been up the river lately in a boat, or that she had just been 
 in the woods, where " some money was tied to a tree," and the like. 
 The hallucinations continued, and even became more marked. She heard 
 voices, reached out her hands to fancied visitors, talked to the wall, 
 spoke of the girls upstairs " who have talked " about her, and quite 
 marked was the fact that she picked up imaginary threads from the 
 bed-clothes. Artificial hallucinations could be produced by rubbing her 
 eyes. On such occasions she said she saw " a fire-place," " woodwork," 
 " shelves," " a woman in a blue dress," " all sorts of things." Reading 
 tests showed fair results at times ; again, she made glaring mistakes, such 
 as reading "pollies" instead of "1903." When questioned about events 
 in her life she varied a good deal, sometimes gave perfectly absurd 
 answers, e. g., that she was born in 1881 ; again, the answers were ap- 
 parently perfectly correct. A few tests to study her ability to retain im- 
 pressions (Merkfahigkeit) yielded results which would make one think 
 that this was very poor; but the question of attention was not sufficiently 
 considered at the time, so that we must not lay too much stress on the 
 results, all the more so since it was found repeatedly that at the end of 
 an examination she remembered incidents which had taken place at the 
 beginning of it. Her talk may be illustrated by the following examples. 
 She said spontaneously: "I'll never see my mother any more; she has 
 been trying to hold up since she was lost." And then, pointing to the 
 nurse, she said, " This is my mother. Please let me go. There is noth- 
 ing for me to stay here. That's what I was, freezing. It seems just like 
 she came in the window." (What do you mean?) "Well, don't you 
 know there is a store in front of the bridge that comes right down to a 
 point of lace. She lived there, or she did when I lived there," etc. 
 " Down to a point of lace " is evidently a paraphasic turn, a trait which 
 may be further illuustrated by the following samples. " We were com- 
 ing down the ref road ... I can't tell you where it is, it's the mostly 
 jardmar, in the mell, mell jar, in the worsted mill yard." Or in speaking 
 of Chattanooga, she said, " Chattanulgo, Challamutta "; and on one occa- 
 sion when she heard a telephone ringing, she said it was the Chattanooga 
 ringing, or " You are the gentleman I not in the grocery store." 
 
 In general it may be said, as is the case in these patients, that though 
 the talk showed some shifting of subjects, loosely connected, it was not 
 that which made it difficult to follow it ; nor was this a very marked trait, 
 as she kept often to the subject she had chosen fairly well; but it was the 
 fact that she told of delirious experiences which we knew nothing about, 
 and the talk was further obscured by the paraphasia.
 
 78 DELIRIUM PRODUCED BY DRUGS 
 
 After the two weeks the patient gradually became perfectly clear, 
 orientation was excellent, the hallucinations disappeared, and she talked 
 very naturally. It was all the more striking that with this clearness she 
 retained for a number of days a belief in some of her delirious experi- 
 ences, without however showing an adequate affective reaction. Thus she 
 claimed that the nurse had told her that she had killed a man, and said 
 she knew it was her husband. She explained that at home her husband 
 discharged a nurse, and that the latter followed him to the barber shop 
 and shot him through the thumb. When questioned retrospectively about 
 the events which had occurred in the hospital, it was found that the 
 very first part was practically a blank to her, but that after that she re- 
 membered quite a number of things, which, however, were not put 
 together in anything like a sequence. She was taken home before she 
 had entirely ceased to believe in some of her delirious experiences, 
 although she did not at all react to them. 
 
 Case 2. — Mrs. W., aged 30. In the hospital from May 23 to August 
 3, 1903. Her maternal grandmother was insane for fifteen years until 
 her death at the age of 60 ; her mother had repeated attacks of " nervous 
 prostration," and one of the mother's brothers was an epileptic. A 
 paternal uncle had an attack of insanity. 
 
 The patient herself had " nervous prostration " when 22, a condition 
 in which she complained of considerable physical weakness, also of much 
 pain in head and spine, and is said to have been very " hypochondriacal." 
 She was in bed for months. She was married two years after the onset, 
 but only two years later, i. e., four from the beginning, was she con- 
 sidered really well. 
 
 Three months before admission the patient is said to have had an 
 attack of " grippe." She was weak after it, complained of palpitation, 
 and was considerably worried about it. She had to remain in bed, be- 
 came nervous and irritable, and more and more worried about her 
 condition. It is claimed that she would sometimes stare for half an hour 
 at a time. A month before admission she attempted suicide for the 
 first time, and was henceforth very insistent in her attempts. Three weeks 
 before admission there were occasional spells of mental clouding, and for 
 a week before admission she had been rambling, noisy, resistive; finally 
 confused, untidy, hallucinating, eating almost nothing for some days. 
 
 Fortunately we have a good account of the drugs which this patient 
 received. It must be remembered that she was admitted on the twenty- 
 third of May. From April i to 11 she was given 10 grains of bromide 
 at night. From the eleventh until the twenty-seventh it was replaced 
 by 18 grains of trional, repeated if necessary. From April 26 to May 3 
 she had 60 drops of Tr. hyoscyamus a day. From May 3 until admission 
 she had regularly, at first 60, then 120 grains of bromide, plus 15 drops of 
 Tr. gelsemium a day. In addition to that she had, for the week preceding 
 admission, altogether 2^ grains of morphine and j^^ of hyoscine. And 
 finally she was given Tr. passiflora, 5 to 10 drops, every 2 to 3 hours ; later, 
 30 drops at longer intervals.
 
 DELIRIUM PRODUCED BY DRUGS 79 
 
 The patient was admitted with a temperature of ioo° F., sallow appear- 
 ance, foul breath, heavily coated tongue, pulse lOO. She was restless, 
 shouted for her husband, spoke of hearing her people murdered, of seeing 
 coffins, men with revolvers. She frequently seemed to pick up things 
 from the bedclothes, and when questioned said she saw bugs and threads. 
 Her voice was thick and her stream of talk fragmentary. She was com- 
 pletely disorientated. At the morning visit her physical state was the same 
 as described. In addition it was found that there was no tremor, but 
 marked exaggeration of reflexes, with pronounced ankle clonus, in- 
 exhaustible on the right side, exhausted after lo to 12 motions on the 
 left. Babinski absent. She lay in bed quietly, mumbling something to 
 herself, occasionally calling out, evidently in response to hallucinations, 
 sometimes picking imaginary things from the bedclothes. She appeared 
 dull. The mood was indifferent, there was neither fear nor any evident 
 depression or exhilaration. It was sometimes very difficult to attract her 
 attention, again more easy. Sometimes she commented on slight, quite 
 unobtusive noises, such as a distant train. Orientation was poor. She 
 said she did not know where she was, did not know the people, but she 
 gave the month as May, the year as 1903, then 1902. Again, she said she 
 was at her sister's house, but frequently called the doctor " doctor," the 
 nurse " nurse." 
 
 Her talk may be illustrated by the following. When asked how long 
 she had been sick, she said, " I have been sick eight or ten weeks — that 
 is if I speak right — now my folks tried to lose me, they were hunting 
 for me." (Did you see them?) "I could not hear a sound, only her 
 [nurse], and she will kill me" (no affect). "They all say I was afraid 
 because I went to a store on Tremont Ave. They would not let me 
 have — well, she would not let me — have anything to do — you remember 
 that [to nurse] — she can't find out. I'm growing hazier and hazier — but 
 this forenoon, well, I'll tell you what she did. I see her object in it 
 now. I hadn't thought of it. I have been moved so often. We have 
 moved around in the daytime — in the night — we have moved all around, 
 I don't know how many things," etc. 
 
 What is not brought out in this sample is her paraphasic turns, which, 
 nevertheless, were quite marked. Thus she said, in good connection, 
 "That is all the satisfaction I can get, and I am satisfaction." Or when 
 asked the day, she said, " I don't know, I haven't seen a map for ages. 
 I am just 8:30 May something." Or again, " Are you the gentleman that's 
 marrying this house?" Or, "He make it distinct enough that I would 
 not get well. Distinct, extinct enough, he made it excitement enough," 
 etc. 
 
 When asked memory questions she varied, evidently owing to her 
 variation in responsiveness. She gave her age correctly. (Have you a 
 child?) "Yes, three years ago" (correct). (Is the child living?) "No, 
 dead" (incorrect). (How long ago since it died?) "Two years." 
 (What did it die of?) "Still-birth." (What?) "Two years ago the 
 8th of February." (What happened then?) "A boy was born to me."
 
 80 DELIRIUM PRODUCED BY DRUGS 
 
 (How long did he live?) "Oh. I was taken sick on the eighth and 
 he was born on the ninth." (Is the boy living now?) "Yes." (What is 
 his name?) She gave it correctly. (Have you ever lost a child?) " No" 
 (correct). (How old is your boy?) "33." (No, your boy?) "3" 
 (correct). Then she was asked, "What is 9 times 15?" She said 19. 
 (7X13?) "21." (8X9?) "72." (16X12?) "72." (What is the 
 capital of the U. S.?) "Boston." (Capital of Maine?) "45." (Capital 
 of Maine?) "Capital of Maine? 75" (What is 75?) "A number." 
 Then she was again asked impressively, and she said correctly, " Augusta." 
 
 In addition to the hallucinations above described, artificial hallcina- 
 tions could be produced by rubbing her eyes. She said she saw " a horse- 
 car on the street," " a post," " a white post," " people and a dog." (What 
 kind of people?) "Mostly Chinese women." (What color of dresses?) 
 " Mostly white dresses. I saw a cap just now — all kinds of things, houses 
 and everything else." When told to open the eyes she said, " Now I see 
 a bunch of grapes." Asked what she saw on the ceiling, she said, 
 " Grapes — single grapes, small and large ones." 
 
 Just as we found in the other cases, this woman made striking mistakes 
 in her reading. 
 
 This condition lasted about ten days, while the more marked symptoms 
 gradually faded, the tongue became clean, the reflexes normal, the 
 orientation became much better, the paraphasia was slight, the talk was 
 much clearer, but in spite of all this improvement she continued to 
 believe in the delirious experiences and for a time hallucinations per- 
 sisted. Although she finally cleared up altogether, she held on to some 
 delirious experiences almost to the end, while at the same time she 
 showed a certain mental sluggishness. 
 
 Case 3. — Mrs. E., age, 43. In the hospital from July 22 to September 
 15, 1904. Heredity is denied, and the patient has never before been insane. 
 A year before admission she had a good deal of worry. She lost flesh 
 and got weak, slept poorly, and it is stated that at that time she took 
 a considerable amount of morphine, but that she had not taken any for 
 three months. For about three weeks she has felt very exhausted, slept 
 poorly, complained of many pains, and it is stated that a great many 
 drugs were then given her, but we were unable to find out just what. She 
 got steadily worse, finally somewhat confused, and three weeks before 
 admission she was sent to Boston. There she had to be looked after, 
 had to be dressed, fed, and gradually became excited and at times fearful, 
 confused, so that twelve days before admission she was taken to a small 
 hospital, where she was dull, untidy, restless, had hallucinations of hear- 
 ing and vision. 
 
 In this hospital she was again given hypnotics, but as has often been 
 our experience, the guilty physicians are very apt to be exceedingly gen- 
 eral in their answers to letters of inquiry about drugs. 
 
 The patient was brought to us in a state of marked dulness and 
 hebetude ; she showed a tendency to keep her eyes closed, was untidy, 
 her mouth was dry, presented sordes, the tongue was heavily coated, the
 
 DELIRIUM PRODUCED BY DRUGS 8 1 
 
 breath foul, the pulse rather weak (loo). The internal organs presented 
 no abnormality. The reflexes were normal. There was no terror. She 
 lay muttering, speaking indistinctly and thickly, but when her atten- 
 tion was attracted her talk was much more connected and the voice 
 much less thick. Sometimes it was easy to attract her attention; again, 
 difficult. But it was quite striking that she repeatedly caught up state- 
 ments made within hearing and commented on them. Her train of 
 thought was at times difficult to follow, partly on account of paraphasic 
 utterances, partly because she spoke of things irrelevant to the situa- 
 tion. But she kept on the chosen subject remarkably well. The answers 
 were often quite irrelevant, evidently because she either paid no atten- 
 tion to the question or because of her paraphasic turns. We may give a 
 few examples. When asked what is two times two, she said " two over " ; 
 and again, asked what's two times two, ' that what I said, you would 
 think I was crazy, a woman of 75 to make me marry" (she had spoken 
 of that before), "to be asked why I did not marry such a woman" 
 (paraphasia). Then turning to the nurse: "Florence. No, that isn't 
 Florence. I said ' put that feather, over there,' and Florence said, * No, 
 I won't put that feather over,' " etc. 
 
 The data of her life were at times given well, again poorly. She was 
 totally disoriented, miscalled people. Even simple multiplications were 
 done poorly. Her mood was either indifferent or somewhat euphoric. 
 Hallucinations were present and frequent, especially those of hearing, 
 and to a lesser degree those of sight. Quite striking were the tactile 
 hallucinations, or tactile and visual combined, which were manifested by 
 her imaginary picking up objects. Her ability to retain impressions tested 
 in the ordinary way (given a number of 4 digits to remember) appeared 
 poor, but here again we must add that such a test is only of value if 
 the mental responsiveness is taken into account. Paraphasia was pro- 
 nounced. Interesting were the results when objects were shown to her. 
 They were evidently in part due to a disorder in apprehension, so clearly 
 brought out in Case 4, and quite striking was also the influence persevera- 
 tion. The following samples may be mentioned. (Knife.) "Brick 
 house." (Knife.) "Those are—" (thinking). (Tell me.) "Knife." 
 (Bunch of keys.) "A key ringer — ringer for keys." (Watch.) "Keys." 
 (Charm.) "A charm." (Spectacles.) "Those rings which go on." 
 (Cuff.) "Keys, cuff of keys with a key-note in it." (Pink.) "Pink." 
 (Palm leaf fan.) "Fan." (Brown book.) "Bible" (Hand-glass.) 
 "Looking-glass." (Comb.) "I don't know — that's my black comb." 
 (Hair-brush.) "Comb. It's a hair brush." (Closed fan.) "A fan, a 
 parasol, a very little parasol." (Opened fan.) " A fan, a parasol." 
 (Cuff button.) "A gold ring." (50 cents.) "A quarter." (25 cents.) 
 "A quarter."" (50 cents.) "A quarter." (5 cents.) "10 cents." (One 
 cent.) "5 cents." 
 
 Three days after entrance the attention was attracted with greater 
 ease, but the paraphasia persisted to a marked degree. She read very 
 poorly. For example, when made to read " bats have proportionately the 
 
 7
 
 32 DELIRIUM PRODUCED BY DRUGS 
 
 longest ears and the oddest shaped noses in the whole animal kingdom," 
 she read " Bates properly continue the largest earnestly and clearly noses 
 of the kind, of the innumerable kind." When she was shown pictures she 
 showed marked abnormalities, pointed out birds where there were none, 
 called a piece of bread in the hand of a little child '' a cucumber squash," 
 saw " a lobster claw " on a piece of paper which contained only indistinct 
 marks, not at all suggestive of a lobster claw to a normal person, or 
 she caller three lambs "three cans" (paraphasic?). At that time she was 
 still disoriented as to place. In regard to time she knew the month and 
 year, but nothing more. She miscalled persons, but not consistently. She 
 gave no one a correct name, but called the doctor " doctor," the nurse 
 " nurse." The hallucinations continued. She heard voices, and still picked 
 imaginary things from her bed-clothes. In regard to the disorientation, 
 it may be mentioned that she thought she was at home, or in the house of 
 a friend. She repeatedly told of delirious experiences. 
 
 In a few more days the hallucinations left, she became perfectly clear 
 and the attention was good, but she still called the place wrongly, still 
 uttered delirious experiences. Thus she told of an accident which had 
 happened in which her mother had been injured, and claimed that the 
 examining physicain had been called in and had operated on the mother at 
 her home. Gradually she cleared up entirely, not only from her delirium, 
 but from the condition which had originally led to the giving of drugs. 
 
 Case 4. — Amelia G., aged 39. Dressmaker. Admitted January 11, 
 1905. 
 
 The patient has some psychopathic heredity, and it is said that she was 
 always of a suspicious nature, was easily frightened, and inclined to be 
 quite hypochondriacal in the sense of making a great deal of small ail- 
 ments. For ten years she complained much of pain in the neck and head, 
 but on the whole was able to do her work. 
 
 Six weeks before admission she complained more of the pain, became 
 depressed, despondent, listless ; sometimes she was restless. 
 
 Five days before admission she became more depressed, self-accusatory, 
 and sat for hours without speaking. Soon after this she began to " talk 
 queerly," said people were dead, that she had killed six little children. 
 She also said that the top of her head was " blown up." She claimed that 
 her mind was gone. At the same time she showed indications of morbid 
 self-reference, thought things which were done had a peculiar meaning, 
 and she fancied that people looked at her. A few days before admission, 
 hallucinations began ; she answered voices, and she saw " red devils crawl- 
 ing over the sister's jacket," "a little angel walking round the rim of her 
 drinking cup." She was often seen staring. 
 
 For about a week she had eaten very little and had slept very poorly. 
 
 Now, this woman had been given liberal doses of bromides in the six 
 weeks preceding her admission to the hospital. We were unfortunately 
 unable to find out the exact doses, but it is said that she was given a 
 teaspoonful of a bromide mixture every three hours. The fact that at 
 entrance she had marked acneform eruption on her body also supports the
 
 DELIRIUM PRODUCED BY DRUGS 83 
 
 supposition that she had been heavily dosed. Besides these bromides, she 
 was given hypodermic injections, the nature of vi^hich we could not find out. 
 
 At entrance the patient showed, as was stated, an acneform eruption; 
 the tongue had a heavy brown coat; her breath was foul. Her gait was 
 somewhat unsteady, resembling that of cerebellar ataxia. But there was 
 no tremor, the reflexes were normal. The pupils could not be tested on 
 account of lack of co-operation. She showed marked tenderness and pain 
 over the joints of the legs, but no swelling. Her urine showed a slight 
 trace of albumin, but nothing pathological otherwise, except a very high 
 specific gravity, .1041. Temperature normal. Pulse and respiration 
 showed nothing of any consequence. 
 
 She wandered aimlessly about, presenting the uncertain movements 
 above described. Her expression was strikingly empty, but not immobile. 
 She made the impression of being absorbed in vague thoughts, ard very 
 often she did not answer questions, or what she did say had no bearing 
 on what she had been asked, but was either a vague allusion to the 
 " Blessed Virgin " or the like, or a repetition of something she happened 
 to hear, and the result was the same whether complicated or the most 
 simple questions were asked. But she showed her tongue, and reacted 
 quickly to pin pricks. Quite striking was an aimless resistance, blind in 
 character, yet without an afifectful background to it, making rather the 
 impression of a tendency to perseveration, a trait which was later on 
 brought out more clearly. Interesting is the fact that with this there was 
 at times a tendency to catalepsy, and above all a marked, though not 
 consistent, echopraxia, even to tests. It should be noted that in spite of 
 all these traits she at times occupied herself with the physician, fumbling 
 aimlessly about his clothes and the like. 
 
 Next day the condition was quite different and remained different for 
 about a week, after which time it very gradually shaded into a typical 
 state of manic depressive retardation, which persisted so long as I observed 
 her. The condition which developed on the second day, and which we shall 
 presently describe, was a delirious state, and for some weeks after the 
 height of it was passed the slight delirious traits persisted, masking the 
 manic-depressive retardation, so that for quite a while the case presented 
 considerable difficulties to the correct interpretation. 
 
 During the delirious condition she was at first completely disoriented 
 as to place, persons, time, even the time of the day. Whether this had 
 been so on the first day we were unable to decide, because she did not 
 answer questions. It could be established, after the first day, because 
 she responded more readily, although she had a marked tendency from 
 time to time to get into a similar staring condition as at first, and even 
 to become decidedly drowsy. These variations in her responsiveness were 
 quite marked, so that at times it was impossible to attract her attention. 
 When thus absorbed she did not react to pin pricks, and, at these times 
 also, it was found that she would firmly hold on to anything which she 
 happened to have in her hands, so that it could not be taken away from 
 her except when it was possible by putting some other object in front of
 
 84 DELIRIUM PRODUCED BY DRUGS 
 
 her eyes to forcibly attract her attention to that. Again, when looking at 
 anyone, she would follow that person with her eyes when he moved about. 
 All this made the impression of a peculiar fascination and perseveration. 
 During this time she lay in bed, often appearing rather dull. She halluci- 
 nated, saw " staggering things with long legs," " a bird " in the physician's 
 hair, " lots of children at the end of the hall," or she saw faces in the 
 transom, and heard voices. But she had evidently no hallucinations of 
 touch. Her talk, which was rather scanty, was, however, clear, and there 
 were only occasional paraphasic turns in it, but these were distinct. She 
 produced, however, a number of delirious experiences. She said she had 
 been " in a dry goods store this morning," that she had gone down a long 
 street, and the like. 
 
 The mood during all this time was strikingly indifferent, even when 
 she uttered occasional depressive ideas. 
 
 We then made some experiments daily in order to study more closely 
 the hallucinations, the process of apprehension, and her ability to retain 
 recent impressions. In all these experiments the question of mental re- 
 sponsiveness had to be taken into consideration, so that we also made 
 some tests regarding this.^ 
 
 Let us first consider the hallucinations. Like all the other cases, this 
 patient showed marked artificial hallucinations, i. e., when the eyes were 
 pressed upon and she was asked what she saw, she said, for example, " a 
 whole pile of black iron rails " ; later, " I see a little girl of 13 or 14 hold- 
 ing a doll." (What kind of dress has she on?) "A gray one." "I see a 
 baby carriage." She also said, " I see a man," or again, " It looked like 
 a yellow suit with brown buttons on it." As will be remembered, it was 
 Liepmann who first showed that such hallucinations could be produced in 
 alcoholic deliria. 
 
 When pictures were shown to her the halluciantions were also very 
 marked, just as had been the case in Mrs. H. Thus in one picture which 
 she first described quite well, she added, " and there is a man crawling 
 under the fence." In another picture she pointed out a cat in the grass, 
 where there was none. After having described the essentials of a third 
 picture correctly, she added, pointing to rather small, indistinct geese, 
 that they were birds. A small brown chicken she called a squirrel. 
 Finally she saw " a big snake and a big green lizard." (The picture 
 showed a patch of grass.) When she was shown a fourth picture she 
 again described the essentials correctly, but when she came to an in- 
 distinct chick she said, " There is something here but I can't see it." Later 
 she saw " bugs running up the shrubbery," and finally " a long green 
 snake." In other words, the patient began invariably by describing the 
 picture correctly. That was at a time when her attention was attracted by 
 a new picture, but soon she began to hallucinate, and as we shall presently 
 
 * These experiments I made in conjunction with my friend and asso- 
 ciate, Dr. S. I. Franz, to whom I wish here to extend my thanks for his 
 assistance.
 
 DELIRIUM PRODUCED BY DRUGS S$ 
 
 point out, she began to see indistinctly, and when one watched her further 
 she was very apt to go oflf, as it were, i. e., to get into a staring state 
 similar to the one described on the first day, or she got distinctly drowsy. 
 That she does not see well we infer from the fact that she pointed 
 to the chick saying, " I cannot see that." However, this was rather iso- 
 lated and usually she hallucinated. Some years ago I had occasion to 
 observe a case of Korsakow's psychosis quite early in the course. This 
 man resembled in many ways the patient under consideration. In that 
 case it was very evident that he had periods when his vision was very 
 indistinct. He also hallucinated at times during these periods of indis- 
 tinctness of vision; more often this was not the case. The Korsakow case 
 differed very markedly from Miss G. by making a much more natural 
 impression, but from time to time he had peculiar short spells in which he 
 seemed to wander, would not respond, and sometimes even his attention 
 could not be attracted for the space of a minute or so. My attention was 
 first called to this condition while I was making a sensory examination. 
 He would answer promptly for a time, then suddenly he could be touched 
 or pricked without making any response. In order to study this more 
 carefully we applied the following tests. We read to him columns of 
 thirty-two figures each, among which five threes were irregularly dis- 
 tributed. He was asked to tap the table every time he heard a three. 
 He would often allow from one to five threes to pass unnoticed, on one 
 occasion fourteen in four lines, and altogether 14 per cent. When this 
 man was shown series of letters (we used quite large ones) or pictures, 
 he would at times name or describe them very well. At other times he 
 would say, " it's dull," or " it's blurred," or " it's going," or simply, " I 
 can't see it." Although the most frequent result was that his vision be- 
 came merely blurred, he, at times, hallucinated like Miss G. For example, 
 on one occasion, instead of seeing a letter he said he saw " a procession of 
 the Knights of Pythias." A few times he also had auditory hallucinations 
 in such periods. Questioned about these states he said, " My mind 
 wanders"; or again, "I get forgetful at those times."* We see, then, 
 that this patient had short periods during which his " mind wandered." 
 In these, his attention could at times not be attracted; at other times he 
 showed a peculiar visual disorder, and with it a tendency to hallucinations. 
 The analogy with the case of Miss G. is obvious. The most likely cause 
 of this visual disorder seems to be a disorder of accommodation and fixa- 
 tion. There can be no doubt but that this indistinctness of vision plays a 
 part in the production of the visual hallucinations, or more correctly, 
 illusions. The most important part, however, we must admit to be the 
 
 * An interesting feature about the case was quite marked variation in 
 the blood-pressure, distinctly perceived by the touch. But I was never 
 sufficiently satisfied to declare that they were synchronous with these 
 periods. On one occasion Dr. Amadon established the fact that the 
 fundus, which in the beginning of the ophthalmoscopic examination ap- 
 peared normal, later was much paler.
 
 86 DELIRIUM PRODUCED BY DRUGS 
 
 mental alteration, namely, the peculiar dipping down to lower levels of 
 consciousness — if this term may be permitted — a condition of mental 
 dissociation analogous to dreaming or to the hypnagogic state, in which 
 hallucinations are also present. And we all know that in the state pre- 
 ceding sleep our vision becomes indistinct, as everyone has experienced 
 when trying to read a book while having difficulty in keeping awake. 
 
 We will now return to the case of Miss G., and to the experiments on 
 the proc.ss of apprehension. We wished to see whether a short exposure 
 of letters or words or pictures was sufficient for her to apprehend correctly. 
 We used for that purpose a small screen of a photographic apparatus, the 
 exposure of which varied somewhat between one tenth and one fourth of a 
 second. Among seventy tests we found that sometimes we obtained, even 
 with the shortest exposures, remarkably good results, which in no way 
 differed from the normal. This was especially the case with simple letters 
 or with words. At other times the results were remarkably poor, and again 
 the patient hallucinated. The influence of the clearness of the object was 
 evidently of some importance. Thus, when an indistinct bird was shown, 
 she said, " I see three cows in a field and a man coming along with a rake 
 over his shoulder." Bonhoeffer, in studying his alcoholic deliria, has 
 pointed out that by means of the sesthesiometer we sometimes get normal, 
 again very bad results ; in fact, his findings are perfectly analogous to ours. 
 We may say that, from time to time, there is a most profound inability to 
 apprehend, but that this is due entirely to the specific delirious alterations, 
 the dipping down to lower levels of consciousness ; while at other times 
 we obtain normal results. 
 
 Somewhat more complicated is the study of the retentive faculty 
 (Merkfahigkeit). When we gave the patient eight consecutive figures to 
 repeat, she was able to give on an average about four; a few times, how- 
 ever, she gave seven and six, sometimes none or only one (nineteen tests). 
 It is possible that seven and six represent her normal limit. 
 
 Other tests were the following. The patient was given pairs of words 
 — (i) words connected by habitual association, such as "bread and 
 butter"; (2) pairs of words connected by internal association, e. g., "head 
 — hair"; (3) pairs of words which were not connected at all, such as 
 " screen — ball." After times varying from thirty seconds to two minutes, 
 thirty minutes, an hour, or even one or two days, she was given the first 
 word and had to supply the second. We found that she was unable to 
 retain words which were not connected, but we made few experiments with 
 thejc. Among the words with internal connection she retained 31 per 
 cent. ; among those with habitual association 57 per cent. It was generally 
 found that when she was able to retain the words for thirty seconds she 
 also cojld retain them for much longer periods, and the results with 
 habitual associations were even strikingly good when she was asked two 
 or three days afterwards." In this connection we may also mention some 
 experiments with pictures. Three days after she had been shown certain 
 
 "These word- pair experiments were made with twelve different word- 
 pairs on five different occasions.
 
 DELIRIUM PRODUCED BY DRUGS 8/ 
 
 pictures she was able to pick out correctly the five shown among twelve. 
 And similar evidence of her ability to retain impressions was seen from 
 day to day when questions about incidents of former interviews were 
 asked. I doubt whether the results would have been the same in alcoholic 
 delirium, for which Bonhoeffer claims such a memory defect, although he 
 is not very explicit about it. At any rate, in view of these results, it 
 seems very questionable whether we can speak in this case of a memory 
 defect independent of the general clouding of consciousness. It might very 
 well be that in alcoholic deliria, which have many points of relation with 
 Korsakow's disease, there exists an independent memory defect, while this 
 is not true in cases here under consideration. Finally, experiments similar 
 to those recorded in relation with the Korsakow case above mentioned were 
 made, i. e., the patient had to tap every time a three occurred in a column 
 of figures read to her. She omitted 34 per cent. These tests were made at 
 two different periods — (i) when the delirious traits were more in the 
 foreground; (2) when the retardation was more pronounced. During the 
 former there were present 16.5 per cent, omissions, and 4.8 per cent, slow 
 reactions; during the latter, 51.5 per cent, omissions, and 4.8 per cent, 
 slow reactions. 
 
 If we summarise the clinical picture of these drug deliria, we 
 find in the first place on the physical side invariably a coated 
 tongue, a foul breath, sordes at times. We also find occasional 
 slight febrile movements, sometimes unsteadiness of the gait, 
 increase of reflexes, and some slight, but quite inconstant, tremor, 
 The speech defect I am inclined to attribute in part to the bad 
 condition of the mouth, in part to the clouding of consciousness, 
 because it is very striking how much better these patients speak 
 when they are aroused. There is no cyanosis and no flushing; 
 on the contrary, the complexion of these patients appears rather 
 pasty. 
 
 On the mental side we find first of all a certain dulness and 
 hebetude, so that it is at times difficult to arouse these patients, 
 while at the same interview it may be quite easy; and we have 
 repeatedly noted that in spite of a marked dulness, unobtrusive 
 noises may be commented upon. In harmony with this dulness 
 is the fact that we often find a certain drowsiness even in the 
 mildest cases. We shall later return to this. 
 
 The most marked alteration is a constant tendency to dip 
 down to a lower level of consciousness. This seems to me a 
 more correct formulation than to speak of an attention disorder, 
 which term is used, for example, for the very different alteration 
 underlying flight of ideas ; although it is to be expected, and
 
 88 DELIRIUM PRODUCED BY DRUGS 
 
 experience actually teaches us, that the lowering of conscious- 
 ness which we here speak of should lead to an attention 
 disorder, as a partial secondary manifestation, which then, of 
 course, presents itself in a very different setting than that which 
 produces a flight of ideas. When the consciousness sinks to this 
 lower level we have a condition somewhat akin to sleep, inasmuch 
 as there is a general dissociation; spontaneous trains of thought 
 arise, not connected with the outside world or with reality, very 
 similar to dreams. At the same time there are hallucinations of 
 various senses, more especially sight, hearing, and touch. These 
 hallucinations may be produced artificially by rubbing the eyes ; 
 they are also well observed if the patient is made to describe 
 pictures or to read. We have seen that the visual hallucina- 
 tions, or better the visual illusions, are in part at least due to 
 an indistinctness of vision which we have reason to attribute to 
 insufficient accommodation and fixation. However, the essential 
 factor in the production of these hallucinations is evidently the 
 general dissociation for which we find an analogy in the hypna- 
 gogic hallucinations and in dreams, and indeed it seems not 
 improbable that hallucinations are most frequently produced by 
 a dissociation of some kind or other. 
 
 It should again be emphasized that this, we might almost say, 
 specific delirious tendency to dip down to a lower level of con- 
 sciousness, is but a tendency, and that the patient can usually 
 be roused, often to strikingly good, connected activity, as was 
 shown in all our patients, especially well in the tests applied in 
 the case of Miss G. The paraphasia seems entirely due to the 
 lack of attention, the inability to concentrated activity as the 
 result of the specific delirious alteration, as Bonhoeffer has 
 shown. 
 
 The disorientation must also be explained on the ground of 
 this delirious change, and we have seen that in these drug cases 
 a memory defect, independent of the specific alteration, can 
 probab)" not be made responsible for this disorientation. But 
 one thing should be mentioned in this connection. We have 
 been struck with the fact that delirious experiences and delirious 
 interpretations are held with remarkable tenacity, even during 
 the convalescent stage, at a time when the patient is otherwise 
 perfectly clear, and it is not improbable that this peculiar ten-
 
 DELIRIUM PRODUCED BY DRUGS 89 
 
 dency, from an explanation of which we would refrain, is to a 
 great extent responsible for the lack of correction which one 
 would naturally expect in such patients who from time to time 
 can be aroused to a connected mental activity. 
 
 As we have stated, the retentive faculty, or the memory for 
 recent events as such, is probably not altered independently, and 
 the same may be said in regard to the memory for old events. 
 
 The train of thought shows some characteristics which resem- 
 ble thc3e of flight of ideas, and are due, as we have said, to 
 the incidental attention disorder, while at other times the con- 
 nection is retained for considerable periods of time. What 
 makes the utterances of the patient at times so incomprehen- 
 sible to us is not this tendency to flighty turns, but rather the 
 fact that delirious experiences are related with which we are 
 not acquainted, and it is further made incomprehensible by the 
 very frequent paraphasic elements. 
 
 The mood is often indifferent, but we have seen in one case 
 a certain euphoria, again a certain whining depression, some 
 indications of apprehensiveness, but never fear. 
 
 So far as the motor side is concerned, we may find a certain 
 restlessness or disinclination to move, but all this seems incidental 
 to the essential delirious alteration : as a rule it shows nothing 
 very pronounced. 
 
 We will finally compare with this picture that of the alcoholic 
 delirium as Bonhoeffer describes it. According to this writer, 
 this psychosis presents in 80 to 90 per cent, of the cases the fol- 
 lowing characteristics. The patient moves about a good deal, 
 and is constantly occupied. His face is congested, his expression 
 anxious. Often he shows marked fear. There is a very pro- 
 nounced tremor, profuse perspiration. The gait may be some- 
 what uncertain, and there is ataxia of speech. We may add 
 here that he mentions occasional eye muscle disorders, which are, 
 however, slight ; and, retrospectively, the patients may speak of 
 double vision. 
 
 The patients do not appear dull, and even at the height of 
 the delirium they can be demonstrated to students, and the 
 impression made on them is that the patient's manner of reaction 
 is not markedly different from the normal ; but the examiner 
 finds that it takes some effort to hold the patient's attention. On
 
 go DELIRIUM PRODUCED BY DRUGS 
 
 a more careful examination, Bonhoeffer established the following. 
 It is possible at any time to force the patient to a maximum 
 degree of attention which does not differ from the normal. This 
 may be shown, for example, by experiments with the aesthesio- 
 meter. A conversation with the patient also tends decidedly to 
 raise his attention to a certain level, but when he is left to himself 
 there is a constant tendency for the attention to reach a lower 
 level, at which time the normal train of thought ceases, and 
 the arising ideas show a marked tendency to become projected, 
 as it were, as hallucinations. During an examination, when the 
 attention is raised to a higher level, hallucinations are very few 
 or totally absent, and the diminished attention shows itself chiefly 
 by signs which are very similar to those of a normal inattentive 
 state, such as a paraphasia similar to the fatigue paraphasia. 
 
 The memory for old events is not interfered with, and simple 
 calculations are done well, as are all habitual tasks ; but where a 
 concentration is needed, and combinatory efforts are required, 
 the patient fails. The retentive faculty, however, is markedly 
 altered. On the ground of these deviations, Bonhoeffer ex- 
 plains the disorientation which in these cases is very marked. 
 He also mentions in this connection a decided suggestibility and 
 a marked tendency to confabulation, which we all know so well 
 from our experience with Korsakow cases. From these con- 
 fabulations he justly separates those which arise from hallucina- 
 tions. 
 
 Bonhoeffer devotes considerable space to the hallucinations. 
 He raises the question whether central or peripheral causes give 
 rise to them. Meynert has claimed that in deliria the projection 
 systems were at fault, and others had found various disorders, 
 such as amblyopias (Magnan), retracted field of vision (Kruck- 
 enberg), disturbance of colour sensibility (Galezowsky). But 
 Bonhoeffer points out how, on careful examination, he was unable 
 to find any of these changes, except perhaps in colour vision 
 He is of the opinion that peripheral changes, if they are of any 
 consequence at all, have to be given a very subordinate place in 
 the production of hallucinations. He mentions casually Mendel's 
 claim that disorders of accommodation have something to do with 
 visual hallucinations, but he takes no position in the matter. In 
 describing the many mistakes which such patients make in read-
 
 DELIRIUM PRODUCED BY DRUGS 9 1 
 
 ing, he says, however, that possibly the difficulty of convergence 
 may partly cause this disorder, since he obtained better reading 
 with monocular vision. He points out the well-known fact that 
 the hallucinations in delirium tremens are apt to be combined, so 
 that entire scenes are hallucinated ; and he emphasises the fre- 
 quency of the illusionary character of hallucinations, which are, 
 after all, frequently a projection of the patient's thoughts. Just 
 as Liepmann, so BonhoefTer found artificial hallucinations pro- 
 duced by pressure on the eyeball, and hallucinations were also 
 produced by looking at pictures, or by the reading tests. 
 
 Now the deviations from this picture are found either in com- 
 plications with other psychoses or with epilepsy; but what inter- 
 ests us here especially is his description of the more severe cases. 
 Such patients are more difficult to fix ; finer tests cannot be 
 applied. They are duller. The motor excitement is coarser, 
 more elementary, the cyanosis is more marked, sweating and 
 anxiety greater, the speech like that in meningitis. Eye muscle 
 palsies are more frequent, as are various other paralytic phe- 
 nomena. Such cases are very apt to terminate fatally. 
 
 If we now compare the two pictures, that of our deliria, and 
 that of the alcoholic delirium as described by BonhoefiFer, we find, 
 in the first place, that that which we have called the specific 
 delirious alteration is present in both. The hallucinations are 
 the same, and here, as well as there, it is easy to produce 
 artificially these hallucinations ; they are seen when pictures are 
 described, and the results of the reading tests, e. g., are practically 
 identical. 
 
 But all this we only find by a careful analysis, whereas super- 
 ficially the two states differ so much that one would never be 
 inclined to mistake the one for the other. That is due, in the 
 first place, to the fact that we find in the alcoholic delirium the 
 dilatation of peripheral vessels, and a tendency to cyanosis, and 
 often evidence of anxiety or fear. The pulse shows more marked 
 alterations in alcoholic deliria. I am inclined to attribute these 
 differences to the fact that the alcoholic delirium attacks persons 
 who are chronic alcoholics, and whose cardio-vascular system, 
 therefore, shows marked degenerative changes. 
 
 A further difference is to be found in the tremor, which is 
 very marked in the alcoholic states, slight and inconstant in the 
 drug deliria.
 
 g2 DELIRIUM PRODUCED BY DRUGS 
 
 Above all, however, the general responsiveness of the patient 
 is different. We have seen that, according to Bonhoeffer, the 
 alcoholics do not appear dull, and often make a strikingly natural 
 impression on a casual observer so far as their manner of re- 
 action to questions is concerned. In contra-distinction to this, 
 we find our patients presenting a certain dulness and hebetude, 
 and it is much more difficult to rouse them than it is to rouse 
 alcoholic patients. It was a very natural supposition to think 
 that possibly this greater dulness might be due to a disorder of 
 apprehension which was added to the delirious alteration, and 
 it was for that reason that the experiments on apprehension were 
 made. They showed us that this is not the case. One might, 
 perhaps, say that we happened to see graver states, conditions 
 of unusually great intensity, and that the more marked conditions 
 of alcoholic deliria, such as Bonhoeffer describes, are quite 
 analogous, but are fatal only for the reason that the cardio- 
 vascular apparatus is weak in the alcoholic conditions. That 
 this explanation is not sufficient, is shown by the marked ten^ 
 dency to drowsiness even in our mildest case. Miss G. There- 
 fore it cannot be merely a question of intensity, but this hebetude 
 seems to be a special feature of these deliria. For some reason 
 or other it seems that although a high level of consciousness 
 can be reached in both kinds of cases, the tendency to sink 
 to lower levels is greater in the drug than in the alcoholic deliria. 
 
 To a certain extent the fact that the alcoholic patient is con- 
 stantly busy may depend upon this same difference. Whether 
 there is, in the alcoholic states, also a certain elementary motor 
 excitability, I am unable to say. 
 
 We have above mentioned the fact that Bonhoeffer assumes 
 the existence of a memory defect for recent events in alcoholic 
 deliria. Our experiments in the drug deliria, although they per- 
 haps do not allow a general conclusion, speak against such an 
 assumption for our cases. And we have also stated that it 
 would not be improbable that alcoholic conditions should present 
 such a change though it be absent in our cases, because we know 
 how often alcoholic deliria run into conditions of Korsakow's 
 psychosis. 
 
 There is another symptom which Bonhoeffer mentions, the 
 nature of which is as yet uncertain, viz. the great tendency to
 
 DELIRIUM PRODUCED BY DRUGS 93 
 
 confabulation which he found in the alcoholic deliria. The 
 "confabulation " which occurred in our cases appeared to be due 
 entirely to the spontaneous trains of thought which were analog- 
 ous to dreams, and which in part were externalised as hallucina- 
 tions. We have, therefore, throughout our descriptions, spoken 
 of the patients " relating delirious experiences." The fact that 
 defects in the retentive faculty seem to have some relation to 
 true confabulation, would suggest the possibility that the absence 
 of confabulation and the absence of a defect of this nature were 
 related ; and, conversely, the lack of confabulation might be used 
 as an additional support for the claim that the retentive faculty 
 is not interfered with. 
 
 We see, then, that although superficially the alcoholic and the 
 drug deliria are so different that the casual observer would never 
 be reminded of the one by looking at the other, they have 
 nevertheless both the same nucleus, i. e., the specific delirious 
 alteration, which is only marked by certain special features char- 
 acteristic of one or the other.
 
 REMARKS ON HABIT-DISORGANIZATIONS IN THE 
 ESSENTIAL DETERIORATIONS, AND THE RELA- 
 TION OF DETERIORATION TO THE PSYCHAS- 
 THENIC, NEURASTHENIC, HYSTERICAL AND 
 OTHER CONSTITUTIONS^ 
 
 By Adolf Meyer, M.D. 
 
 PROFESSOR OF PSYCHIATRY, JOHNS HOPKINS UNIVERSITY 
 
 For years I have been struck with the frequency, not to say 
 uniformity, with which a number of peculiarities of make-up 
 present themselves in the history of the cases which form the 
 nucleus of the disease-group which deserves the name " essential 
 deterioration process," or " dementia praecox," in the sense now 
 generally accepted by most alienists and perfectly intelligible to 
 those who prefer not to commit themselves to any special nosology. 
 I refer to those cases of deterioration in whom we cannot point to 
 any satisfactorily determined and experimentally or clinically 
 demonstrable constellation of outside factors, as we do in alcoholic 
 insanity or in general paralysis. The prototype of the disorder 
 would be those patients who, without any special positive manifes- 
 tations, undergo an apathetic deterioration. Many cases have some 
 positive symptoms in the form of hypochondriacal additions, or 
 paranoic developments with more or less deficient systematization, 
 or some acute mental disturbance of a more or less characteristic 
 type. The term primary dementia is avoided and replaced by 
 essential dementia, because it has been used in a very promiscuous 
 way so as to include also stuporous disorders whether they belong 
 to this dementia group at all or not. 
 
 The main-spring of investigation is the question of establishing 
 the definite constellations which lead to any deviation under con- 
 sideration, so that it may be better understood and avoided or 
 corrected. The present formulae are heredity and stress, or 
 heredity and auto-intoxication, both pointing to matters which 
 can be reached but indirectly and which do not seem to me to 
 
 * First public formulation of the synthetic conception of dementia 
 praecox. January 3, 1905. 
 
 95
 
 96 REMARKS ON HABIT-DISORGANIZATIONS 
 
 touch the working principles of the disease which we want to 
 understand and modify. Heredity is an extremely important 
 statistical fact, and it embraces very largely the excuses alienists 
 have to offer for theii' inability to cope with certain things. In 
 the field of action we are forced to decide what we can do in 
 the face of heredity. Stress undoubtedly involves more of what 
 is directly at issue, but it also is an expression of excuse concern- 
 ing a feature of modern civilization which cannot be changed by 
 the physician. Auto-intoxication is the happy word which has 
 all the advantages of humoral pathology and expresses the prin- 
 ciple of many of the methods of patching up the disordered organ- 
 ism. It sounds like an expression of accuracy, but there are no 
 direct methods of demonstrating anything specific. It is always 
 but part of the disorder and the setting of this disorder is what 
 is to be established. Everything points to evidently rather com- 
 plex constellations, and our aim must be to pick out those factors 
 which actually do the work. 
 
 During the past years more and more dissatisfaction has devel- 
 oped with Kraepelin's notion of disease-process. Already in my 
 review of his fifth edition in 1896 I criticised the arbitrariness of 
 calling dementia praecox a disorder of metabolism, and Stanley 
 Hall has lately given an expression to very sensible criticism in 
 the following remarks : " The terms dementia prsecox, insanity of 
 youth, primary dementia, hebephrenia, and katatonia are all par- 
 tial and none of them are entirely satisfactory. These troubles 
 do not by any means invariably issue in dementia, but if all did, 
 the processes that produced and preceded the lesions, and not their 
 effect, should furnish a truly scientific principle of characteriza- 
 tion and nomenclature. Hegel said of Schelling's absolute, as 
 many since might have said of Hartmann's unconscious, that it 
 was not a true philosophic principle, because " all cows look alike 
 in the dark," meaning that a purely negative principle can never 
 be an adequate explanation. We may say the same of dementia 
 prgecox, which faintly suggests the propriety of giving to general 
 paresis, which almost always has a fatal termination, a designa- 
 tion like thanatic dementia, based upon this fact. Early mental 
 death is a result of the morbid processes we have here to study, 
 but so it is of others. With senile dementia both the facts and 
 the propriety of the name are very different."
 
 REMARKS ON HABIT-DISORGANIZATIONS 97 
 
 Instead of suggesting a disease-process which would be apt to 
 befall any individual without special predisposition, and without 
 necessarily any heredity, I should propose for discussion the con- 
 cept of habit-disorders as suggestive of investigation of fact and 
 of modifiable and accessible factors, also not necessarily depen- 
 dent on heredity. I refer briefly to such cases as the following: 
 
 Patient born in 1874; was healthy, never robust; delicate and social as 
 a child. He avoided boys and cruel sports, talked little ; at about fourteen 
 while his disposition was very forgiving he became somewhat cranky, went 
 little with boys, rather avoided girls, became jealous of his younger sister 
 and resented her resistance to being bossed. He went to church a great 
 deal. From the age of seventeen he did not want the sister around when 
 his friends called; once he maltreated a young lady visitor by shoving 
 chairs against her so that she fainted. For some time the patient was 
 occupied as a clerk, tinally he gave up work, stayed out all night and slept 
 all day. During a sickness, 1896-97, he was very good, asked his younger 
 sister to pray for him so he wouldn't die, but on his recovery he was again 
 very ugly. For about a year he stayed in a dark basement room with the 
 curtains down so that nobody would see him loafing. He resented the 
 bringing in of lights. About July, 1897, he threatened his sister with a 
 razor; he often threw bundles at the mother and sister and often swore at 
 them in the morning. He claimed that the sister told people in the street 
 he was nutty. The patient admits masturbation from the age of nine or 
 ten, up to the age of seventeen, when he fainted while playing hockey; he 
 was carried home, remained unconscious twenty minutes ; he claims not 
 to have masturbated since then, but says he used to think about women 
 because he thought this would diminish the nocturnal emission. He ex- 
 plained that his animosity against the sister increased since one day she 
 and some girls surprised him hugging a friend of hers. He also did not 
 want his sister to call at a certain place on account of immorality being 
 committed there. He thinks he was commented on for being out of work. 
 No evidence of hallucinations, although he thinks women called him names, 
 a soft-headed imp, and nutty. Physicians found him depressed, shame- 
 faced. 
 
 The first diagnosis was sexual neurasthenia, with a change of character 
 at puberty and increasing eccentricity of later years and ideas of persecu- 
 tion and suspicion and irritability against family. Within about five weeks 
 after admission the patient stopped his work at the bakery. He smelled a 
 bad smell, he never had had it before and didn't know whence it came. 
 He refused several meals, said he heard some one say that he was sent 
 here for boarding and somebody whose name he doesn't want to tell 
 called him an imp. In November he developed stupor in which he finally 
 rolled up his eyeballs, became cataleptic, had to be fed. He showed infiltra- 
 '■•'on of one pulmonary apex. He remained in a catatonic stupor for a 
 
 mber of months, and emerged from it with a paranoid form of dementia. 
 8
 
 gS REMARKS ON HABIT-DISORGANIZATIONS 
 
 These notes taken from an old history do not show as good 
 investigation as one might desire, but show the general trend of 
 observation which has been repeated in many cases. 
 
 Another patient who is just now under observation and at pres- 
 ent in stupor may serve as an instance : 
 
 C. H., born 1883. Habit-disorganisation. Typical catatonic deteriora- 
 tion at 21. 
 
 Family History. — Negative, but the father of the patient, a night watch- 
 man, has been moderately alcoholic since early life, occasionally drinking 
 to excess ; premature gray hair runs in his family. 
 
 The patient's mother died at 53, of some obscure lung trouble with 
 haemorrhage just before death. 
 
 Personal History. — The patient was said to have developed normally 
 during childhood, though she was looked upon as " a nervous child," easily 
 startled and subject to bad dreams. She began school at seven, was smart, 
 and applied herself well, but at the age of eleven she seemed to be failing 
 and was thought to be studying too hard; she grew thin, seemed nervous 
 and complained of headaches. When she was twelve years old her mother 
 died, and the patient was then in such poor health that her sister kept her 
 at home. She was then a very quiet girl, often complained of her head, 
 and her sister says : " You could see there was something working on her." 
 The patient had desired to become a school teacher — she admired teachers 
 because they were neat and well dressed. This seems to have been merely 
 a fancy which passed away after she left school. 
 
 Her father's third marriage was unhappy through alcoholism, the family 
 was scattered and the patient lived with her sister. After she began to 
 menstruate at fourteen she brightened up, had fewer headaches and 
 seemed to be in better health. Her sister never suspected any disordered 
 sexual habits, but the patient states that she began to masturbate when 
 nine years old; and she has probably continued up to the present time 
 (masturbation observed in the hospital) ; its effects and whether or not it 
 had anything to do with the failure at school and the later difficulty over 
 work, cannot be proved directly. The patient says however — " It spoiled 
 all my youth and my life — I wasn't like other girls — I didn't want to go 
 out anywhere." 
 
 At sixteen she r.-ent to work in a hammock factory, but the work was 
 considered too hard for her ; she thought the noise gave her headache, 
 and she was afraid of the machinery. She had attacks of nose bleed and 
 finally a diarrhea, so that after five months she gave up this work. Seven 
 months later she took a position in a paper factory where she worked for 
 a few months until it was burned down. 
 
 The patient was now seventeen years old and about this time she had 
 some scalp disease ; her hair fell out and a patch of gray appeared on one 
 side of her head. This worried her intensely; she gave much attention to 
 covering up the spot, and had the hair cut and dyed. She was ashamed to
 
 REMARKS ON HABIT-DISORGANIZATIONS 99 
 
 go out, and when she had the offer of another position she declined it 
 because she feared remarks would be made about her hair. After this she 
 remained at home to look after her father's house. It is stated that she 
 did this satisfactorily, but she complained of headaches and sleepiness in 
 the morning and would lie in bed late; she was alone most of the time, 
 had no companions, and her father worked at night and slept through the 
 day. Her father says she was " a stuck-up girl " and " testy " — especially 
 about her clothing, wishing for better than she could afford. 
 
 Her sister says the patient never showed any desire for the company of 
 young men, and, in fact avoided them, and remarked that she would never 
 marry as she had seen enough of married life (referring to her father's). 
 The patient says, however, that when nineteen she allowed two young men 
 to take liberties with her, but without complete connection as she feared 
 pregnancy. She attended to her religious duties, but showed no excessive 
 fervor. 
 
 During her twentieth year she was complaining of constipation and had 
 a " creepy sensation " in her abdomen which she thought was due to a tape 
 worm. She read quack pamphlets and bought medicine from drug stores; 
 she developed hemorrhoids, became despondent over her condition, and 
 when she was twenty-one (January, 1904) she went to the Polyclinic 
 Hospital for operation. After the operation she complained that the nurses 
 had neglected her and that her bowels were full of gas; she wished to be 
 taken home to die. After ten days she was removed to her sister's house, 
 where she was very sensitive to noises and wished to be quiet. She suffered 
 from incontinence of the rectum for a while, but this has passed away. 
 She did not again speak of the tape worm, but was very nervous if her 
 bowels failed to move daily, and she also expressed the idea that her 
 rectum was closing up. She grew very thin and much run down physically 
 after the operation. 
 
 Two months after the operation she returned to her father's house, and 
 with the help of a hired woman, undertook to do the housekeeping. Dur- 
 ing March and April she had a severe attack of tonsillitis. During the 
 summer she was very quiet, and to the neighbors appeared always lone- 
 some; no friends came in and she didn't care to go out; she suffered 
 from amenorrhea after the operation — she worried over this and also her 
 past sexual misdeeds (patient's statement). About this time she thought 
 she would like to study again and be a bookkeeper; she bought paper and 
 pens, put her desk in order for writing but nothing came of it. At her 
 father's suggestion she used to ride on the cars or sit in the parks ; she 
 apologized for spending money and not working any. All of this time 
 she was sleeping poorly, complained of her head and was despondent about 
 herself. The neighbors say that her father scolded her about the house- 
 work and she often said " I am a good girl " or " I can do nothing right 
 for him." The father denies that he scolded her, but says she got very 
 cranky through the summer and without reason complained that he hurt 
 her feelings or said: "You break my heart." Shortly before she left 
 home she spoke differently to her father — " I have done you wrong, I spent
 
 lOO REMARKS ON HABIT-DISORGANIZATIONS 
 
 your money, you worked fifteen months for nothing, you have no good 
 clothes," etc. She began to be afraid to stay alone at night, and a week 
 before her admission at a party in her sister's house, she remarked — 
 ^'Everybody is looking at me, I don't know why." A few days before she 
 left home she said — " I have been sick a long time and thought I was going 
 to die, but now I think Tom (brother) is going to get sick and die." One 
 morning she prepared breakfast, but would not eat because she had to pray 
 for everybody first — later she ate breakfast. Then followed queer acts. 
 
 On October i, 1904, she went to see the priest and that night she was 
 heard by the neighbors praying. The next morning she went to church 
 dressed untidily, left candles burning in her room and poured kerosene 
 oil on the steps for holy water. That day she threw some things out the 
 window because a curse had been put on her by her father and she didn't 
 wish him to have anything. That night, October 2, she went at ten o'clock 
 to where her father was at work, said she wished to see a priest and spoke 
 of having neglected her church while she had been sick. Her father 
 accompanied her part of the way home, where she later disarranged the 
 furniture and other things, and at midnight left the house in her night- 
 dress ; she was found by a policeman kneeling in front of the church. She 
 told the officer correctly where she lived and returned home with him 
 praying all the while. Later, when an ambulance came to take her to 
 Bellevue, she said — " I am a good girl — my mother is dead — it's all my 
 father's fault." 
 
 At Bellevue she said^ — " / hear angels telling me how to pray when I lose 
 my thoughts — sisters and nuns are around me here to save and purify the 
 world," etc. At times she sang and rhymed, would jump up suddenly and 
 gesticulate wildly and then fall back on her pillow as if asleep ; she ad- 
 mitted that she heard voices, and while in Bellevue she held her right arm 
 under a stream of hot water and sustained a severe burn; she later ex- 
 plained that she did this in order to save the world. 
 
 She came to the State Hospital October 10, 1904. On the ward, during 
 the bath and in bed she presented a state of beatitude, walked with her 
 eyes closed, prayed and sang, with slow gestures and theatrical pathos, 
 responded in a monotonous, unctuous manner — passed from smiles to tears, 
 assisted little when cared for by the nurses, even wet and soiled her bed, 
 and when asked why she did so replied : " Although I'm 22 years old I 
 have been transformed from a big girl into a small baby." Why? "Well 
 the Lord said I was too pure to be a woman, and in order to save the 
 world I had to be once more a baby." 
 
 Her arm was slightly resistive, remained elevated from ^2 to i minute, 
 then dropped quickly and relaxed. Her productions were a monotonous 
 and empty religious jumble, slowly produced in speech and song or mere 
 whispers with devotional gestures, closed eyes and a saintly sufferer's 
 mien, interrupted by some queer acts. The following is a sample of her 
 spontaneous rtterances : " I believe in the Lord God — Father Almighty and 
 St. Joseph — Sweet Virgin Mary pray for us — Almighty God, have mercy 
 on me — forgive me my sins — grant me remission of all my sins (crossing
 
 REMARKS ON HABIT-DISORGANIZATIONS lOI 
 
 herself). . . . Divine Catholic world — now and forever — A-amen — 
 glory be to the Father, Son and Holy Ghost, as it was in the beginning 
 . . . Mary is the branch and Jesus the flower — A-amen — at least you, 
 my friend, sweet Jesus, have pity on me (long pause) that he may lead us 
 into a more pure, good, Irish — divine — Catholic world." She then folded 
 and unfolded the counterpane, continued to whisper prayers, held her hand 
 before her face and licked it with her tongue. She had a correct appre- 
 ciation of things, touched the physician accidentally, and said — " Excuse 
 me, doctor." She noticed the laughing outside and said : " I don't need 
 them — I don't want them to be laughing at me out there — I want to be left 
 alone to say my prayers in peace and quietness . . . now let me sleep 
 in peace and quietness, for I am about exhausted." 
 
 What is the matter, have you any trouble ? "I have been sick, I guess — 
 yes — oh, for four years. ... It came from my stomach, I had stomach 
 trouble — I had bowel trouble — I had chest trouble — throat trouble — face 
 trouble — teeth trouble — nose trouble — eye trouble — compound or complex 
 for me — head trouble — brain trouble and all the quarrelling — father squab- 
 bling and scolding all the time — he sent me out for bug medicine, and may 
 Almighty God give that medicine to the one who started this business — 
 this devil's island." Are you sad? "I was sad but not now, I'm happy 
 now." Are you afraid? "No more, I was dreadfully — of everything on 
 earth — for lo years, since my mother died." Afraid of what? "Every- 
 thing, no one would look at me or talk to me — only about me — they said 
 everything bad about me, that I was a bad girl, but I was pure." She 
 made some reference to her gray hair, and when asked to explain, said: 
 " Part of my hair is gray — that's what near made the world come to an 
 end — they all laughed at me, talked about me, and even drew up a play 
 about me called Devil's Island." She referred to the other people on the 
 ward as " all the good, true souls — I don't know whether they are going 
 to save me or whether I am going to save them." 
 
 All this shows numerous, at times senseless moralising and ecclesiastic 
 reiterations with the undercurrent of salvation achieved or longed for — 
 for herself and the world; no true flight nor a dearth of ideas in the full 
 enumeration of her troubles but again evidence of stereotypy of form, 
 utterance in contrasts and reference to Devil's Island, quarrels at home, 
 being laughed at, etc. " I had worms and the worms had me." — " I want 
 to save everybody and everybody wants to save me." — " I went out for 
 bug medicine and the bugs took my way — I lost my way." — " You're Mr. 
 Tiffany " — an interpretation of Dr. M.'s identity ; also, when asked her 
 own name she replied: "Baby Chadwick of the whole world — Divine — 
 Irish — Catholic world — Amen." 
 
 Physical examination showed increased tendon reflexes ; fine tremor of 
 the tongue, face and fingers. Pupils somewhat variable in size, but react 
 normally; a bright red line appears when the skin is marked, and once 
 when excited (screaming) her whole body flushed deeply; feet and hands 
 cool and moist. Pulse high (i 10-120), small and soft at the wrist; a large 
 burn on the right arm ; slight retroversion of the uterus ; masturbation
 
 I02 REMARKS ON HABIT-DISORGANIZATIONS 
 
 observed. Subjective sensations of pins and needles through her body, 
 " Catholic electricity," and a feeling as if she -were " in power." 
 
 The first night in the hospital she was sleepless — singing, praying, 
 taking off her night dress, kneeling on the floor. Once she assaulted a 
 nurse, jumped out of bed, ran to the window, shouting: "Mr. Sullivan, 
 Mr. Sullivan, save me, save me, I'm lost." The following morning her 
 explanation of this episode was as follows : " Everything went wrong last 
 night, good, pure, true and holy doctor — I led you astray," etc. A similar 
 outbreak of excitement occurred during the physical examination and 
 again the following night. After this she slept and claimed to feel better. 
 She had put her arm under the faucet to save the world — " Good, kind. 
 Catholic doctor, I gave up my whole right arm." She then claimed the 
 nurse was the whole cause of the trouble and was irritable towards her. 
 She later excused her actions by — " I was sick in my head, dizziness in my 
 head — excuse me, doctor, I was out of my head and knew not what I was 
 doing." 
 
 She had an attack of diarrhea just after admission, which subsided in 
 four days, and her pulse also declined gradually to about 90. 
 
 Examination nine days after admission found her quieter, that is, with 
 less spontaneity in productions, but she was still in an ecstatic, dreamlike 
 but not dreamy state. She gave vague accounts of hallucinations, of 
 " thoughts " from God and of commands to scald her arm, of being " in 
 power " (pins and needles) ; she explained that she had called herself 
 " Baby Chadwick " because that's what they had pinned on her blue dress 
 in Bellevue. She was correctly oriented as to place and nearly so as to 
 time. Still called Dr. M. " Mr. T," though she could give his name 
 correctly. She showed a remarkably clear grasp on the remote past, but 
 her statements in regard to more recent events were colored by her peculiar 
 trend, e. g., in regard to her admission she spoke' of being taken to the 
 " sanctuary," " where my bowels moved and my water passed from me — I 
 call it that because I suppose Jesus did the same things I did." She spoke 
 of the bath, as where she had again been baptized. Her attention was 
 variable, but retention was good. A newspaper account of a railroad acci- 
 dent was correctly read, but then queerly elaborated — " It ran over my 
 arm," etc. She gave the Lord's prayer, repeatedly making an omission 
 which she did not appreciate. Calculation was erratic, at times giving 
 random replies. 
 
 Her own description of her condition was very striking, e. g., when 
 asked if she was sick she replied : " I was, but not now, my head was bad." 
 
 Were you out of your head? "No, doctor, I had all my senses and 
 faculties, but I was senseless." When asked why she had spat at the physi- 
 cian she again spoke of being " in power," and said : " There is a power 
 over us and amongst all of us — a holy power — it may have been an electric 
 power — I had all my senses and wasn't out of my head — it was a derange- 
 ment of the mind that came over me." When asked to explain this said : 
 "Well, it seems as if the world was coming to an end' — the 20th century 
 coming or some turn."
 
 REMARKS ON HABIT-DISORGANIZATIONS IO3 
 
 At the end of two weeks she rarely spoke spontaneously, but lay quietly 
 in bed, showed some waxy rigidity in the limbs, kept given positions and 
 vras slow and constrained in all her movements. She gave strange account- 
 ing for her actions, e. g., during an interview she would rise slowly from 
 her chair, explaining that she did so " to be with the nurse " — " to try to 
 be good," etc. 
 
 Why have you been standing? "To try to live." 
 
 Why do you hold up your arm? " For peace." 
 
 At the end of a month she had passed into a pseudo-stuporous state, 
 was more rigid and resistive, did not always respond, though tears would 
 often roll down her cheeks. She held saliva and required spoon feeding. 
 She brightened up a little at the beginning of a course of catharsis but 
 soon relapsed. Occasionally she was restless at night and once when asked 
 where she wished to go, said : " To fight for my life — fight — fight — out — out 
 — out away from here . . . follow me — follow me — I am going to serve the 
 American Army and Navy with my life." 
 
 During 1905 the patient still maintained constrained attitudes ; she sat 
 the entire day with her hands on her knees, her head bent somewhat for- 
 ward and tilted to one side; she rarely moved unless urged to do so; she 
 was profoundly apathetic and careless about her personal habits. As a 
 rule she answered very few questions and then gave mostly stereotyped 
 pious phrases. Often tears were seen streaming down her cheeks. She 
 held saliva in her mouth, sometimes refused food, again ate ravenously. 
 Frequently she would burst out laughing or smile without any cause. 
 
 Since 1906 her behavior has shown little change ; as a rule she is mute, 
 lacks all initiative and is untidy in her habits. There is still a tendency 
 to maintain given positions, and slight muscular stiffness is encountered 
 in the limbs. 
 
 In Other words we have here again a patient with precocious 
 sexual instincts, inefficiency at school, and later in factory work, 
 neurasthenoid symptom — complex with head and intestinal symp- 
 toms, growing seclusiveness, marked disorder of intestinal habits, 
 amenorrhea, and finally development of a peculiar tantrum. With- 
 out any of the causes which are sufficient to bring about a similar 
 dream-like phantastic state, in a form quite different from a de- 
 lirium, or manic-depressive attack, or anxiety psychosis, or hyster- 
 ical dream state, in a condition which was compatible with normal 
 orientation and grasp on the environment, an odd state of longing 
 for an enjoyment of salvation with a strange mystic-allegoric 
 trend of action, interpretation and notions developed, probably 
 most like a hysterical dream-state, but with much more deficiency 
 in corrigible foundation and relation to things as they are. Occa- 
 sionally there are acts of perplexity ; the patient claims to hear
 
 I04 REMARKS ON HABIT-DISORGANIZATIONS 
 
 angels telling her to pray " when she loses her thoughts " ; strange 
 sensations make her feel "in power," telephone-feeling — symptoms 
 of a strange phantastic character. Matters which may come up 
 in dreams, in deliria, come up in a relatively clear state of mind. 
 Unreality and absurdity without any evidence of sufficient cor- 
 rectives by sound habits of thought dominate the tantrum. There 
 is a feeling of deficiency or queerness, clearly in contrast with the 
 manic-depressive feeling of mere difficulty and impotence. The 
 emotional reaction is as erratic and poorly controlled as the intel- 
 lectual appreciation, the ensuing impulses and motor states stamped 
 with a certain monotony, and evidence of cataleptic states. 
 
 The attacks usually take the form of a tantrum of some sort, 
 partly characteristic in itself or through the foundation on which 
 it grows. A large proportion stumble over the interpretation of 
 abnormal sensations, or over sexual experiences. 
 
 Instead of merely appealing to cortex changes of obscure cor- 
 relation, or to equally obscure auto-intoxications, or to arrest of 
 development, I refer to the disharmony of habits, disharmony of 
 those regulations which shape a well-balanced economy : The in- 
 testinal and circulatory functions, the sexual life, and above all the 
 trend of interests depending in its integrity and efficiency on a cer- 
 tain equilibration. I have been led in my thought by the analogy in 
 the development of morphological phenomena. Roux has shown 
 by his experiments on the mechanics of development how each 
 part of the organism has a certain dynamic and morphogenic pos- 
 sibility, but that in many points the shaping to a final perfection 
 depends on regulation of the balance of the simultaneously grow- 
 ing other organs and their functions. Deficient growth or preco- 
 cious growth of an organ disturbs these regulations, and the nec- 
 essary result is a disharmony and every plus is apt to be held 
 up by some minus in another direction. This same principle is 
 eminently valid in functional life, and especially valuable in the 
 most complex of biological regulations — those of mentation. Here 
 a veritably practical and critical presentation of the early work 
 of James has very justly pointed to habits as a unit of observa- 
 tion and biological interest. And it will be our duty to define in 
 actual cases what sets of habits we find interwoven and with what 
 effect. This directs the attention to the investigation of matters 
 which are open to influence in education, and to a more rational
 
 REMARKS ON HABIT-DISORGANIZATIONS IO5 
 
 management of dementia praecox, as well as many other mental 
 disorders ; and habit-disorder is to be treated by habit-training, 
 not by vague encouragement and excessive protection and mere 
 fighting of incidental disorders. To be sure all incidental dis- 
 orders, such as the phenomena usually lumped together as auto- 
 intoxication, must be corrected as far as possible, and their cor- 
 rection gives us a vantage ground on which to begin and promote 
 the more fundamental principle — that of habit-training. And in 
 cases where we see disorders developing, whether on ground of 
 heredity or not, it is this issue which guides us in the concrete 
 plan of teaching and prevention. And since the other elements 
 which are apt to figure in our presentations of etiology, nosology 
 and pathology are much more hazy, it is much more satisfactory 
 to come out frankly with a statement that we wish to make dis- 
 tinctions of various types of habit-disorganization, to study the 
 working of the various sets of activities and habits in the patient, 
 determine their relative values by accurate observation coming up 
 to the mark of the experiment, and shaping our therapeutic meas- 
 ures in accord with these principles. This naturally does not 
 exclude in any possible way the consideration of the factors of 
 heredity, and the disorders of this or that organ, but, on the con- 
 trary, gives every manageable part its working chance. 
 
 In viewing the cases of insanity which are not plainly of exoge- 
 nous origin, we find certain types of combinations of a more or 
 less distinct symptom-picture, course and outcome. In " An At- 
 tempt at Analysis of the Neurotic Constitution," published 1903 as 
 a contribution to the commemorative number of G. Stanley Hall's 
 journal, I specified and briefly characterized the following types : 
 (i) The psychasthenic with its feeling of insufficiency, misplaced 
 tension, apprehension, phobias and impulses, practically as out- 
 lined by Janet; (2) the neurasthenic with great fatigability and 
 irritability; (3) the hypochondriacal with feelings of organic in- 
 sufficiency ; (4) the hysterical with dissociations and the charac- 
 teristic interference by undercurrents of more or less emotionally 
 tinged concepts or thought-habits; (5) the epileptic, fundamentally 
 an abnormal neuromotor reaction type. And finally, a number of 
 groups more closely approaching a certain definite mental derange- 
 ment: (a) The unresistive (responding easily to fever, to intoxi- 
 cation) ; (b) the manic-depressive make-up, described by Hecker;
 
 I06 REMARKS ON HABIT-DISORGANIZATIONS 
 
 (c) the paranoic type with its tendency to suspicions, interpreta- 
 tions, with or without aggressiveness, and finally, (d) the actual 
 deterioration type, which I describe as follows : 
 
 In cases of dementia praecox we find over and over an account 
 of frequently exemplary childhood, but a gradual change in the 
 period of emancipation. Close investigation shows, however, 
 often that the exemplary child was exemplary under a rather 
 inadequate ideal, an example of goodness and meekness rather 
 than of strength and determination, with a tendency to keep good 
 in order to avoid frights and struggles. Later religious interest 
 may become very vivid, but also largely in form; a certain dis- 
 connection of thought, unaccountable whims make their appear- 
 ance, and deficient control in matters of ethics and judgment; at 
 home irritability shows itself, often wrapped up in moralizing 
 about the easy-going life of brothers and sisters; sensitiveness to 
 allusions of pleasure, health, etc., drive the patient into seclusion. 
 Headaches, freaky appetite, general malaise, hypochondriacal com- 
 plaints about the heart, etc., unsteadiness of occupation and ineffi- 
 ciency, day dreaming, and utterly immature philosophizing, and 
 above all, loss of directive energy and initiative without obvious 
 cause, such as well-founded preoccupations, except the inefficient 
 application to actuality. All these traits may be transient, but are 
 usually not mere " neurasthenia," but the beginning of a deteriora- 
 tion, more and more marked by indifference in the emotional life 
 and ambitions, and a peculiar fragmentary type of attention, with 
 all the transitions to the apathetic state of terminal dementia. 
 
 I am inclined to put the emphasis on a deficiency of critical and 
 consecutive thought-habits, with a prevalence of interest in the 
 phantastic, mystic, religious and unreal, owing to deficiency in 
 working interests, which would dovetail with the progressive 
 active course of the world. 
 
 This scheme is open to many supplements, and it will be an 
 especially grateful task to push the inquiry of individual make-up 
 along the lines of changes of constitutional make-up due to trau- 
 matism, to toxic influences, to sexual insufficiency, to the preva- 
 lence of certain thought-habits (especially the estrangement with 
 actuality in the form of occultism), and under the influence of 
 the period of involution and senescence. 
 
 Clinically it is rather remarkable that the above types keep
 
 REMARKS ON HABIT-DISORGANIZATIONS lO/ 
 
 fairly distinct. We find in many presentations of neurasthenia, 
 hysteria, etc., the comfortable and probably usually true state- 
 ment that simple habit-disorganization of most of the above types 
 has nothing to do with insanity, and there need be little fear of 
 its coming on. Experience justifies this comforting remark to a 
 large extent. There is also a certain justification in the strong 
 efiForts of many writers to discourage the uncritical intermingling 
 of these types, in terms like hystero-epilepsy, hystero-melancholia. 
 And Kraepelin's effort of taking most of the endogenous deteriora- 
 tion forms into his group of dementia praecox is in part a similar 
 attempt at being systematic. If we take dementia praecox to be 
 a disease by itself which might befall any one, it is not very 
 intelligible ; we emphasize in dementia praecox the fact of 
 looseness of judgment and consequential thought with prepon- 
 derance of habits of the unreal, with either a gradual deteriora- 
 tion of interests, or more acute collapses over difficulties to which 
 the individual is not equal. We might say that the psychasthenic, 
 as a rule, is not of this type, the hysterical is more organized, the 
 true neurasthenic the same, also the manic-depressive type, and 
 in part the paranoic. In the epileptic, deterioration may occur in 
 the form of epileptic deterioration, or as a typical dementia praecox 
 superceding epilepsy. Psychasthenics are apt to deteriorate to 
 the level of lack of initiative of the dementia praecox class. 
 Whether plainly and simply hysterical individuals are apt to 
 develop the characteristics of the dementia praecox complex is 
 denied by some, while Janet claims that every year a few of their 
 cases of hysteria have to be transferred to the service of mental 
 disease on account of deterioration. Many cases of dementia 
 praecox begin with hysterical symptoms. The whole symptoma- 
 tology of catatonia shows so many traits in common with the 
 phenomena of hysteria and of hypnotism that certain French 
 authors look upon it as a hysteriform psychosis. I should like to 
 refer to a very interesting case that was looked upon as dementia 
 praecox notwithstanding a plainly hysterical onset after confine- 
 ment, but which recovered completely, and in whom investigation 
 showed that there were none of the manifest and plain antecedents 
 of dementia praecox. This is a patient whom I turned over to a 
 pupil of a prominent worker on hysteria, who declined recognizing 
 in it the hysterical complex and gave a verdict of dementia praecox
 
 I08 REMARKS ON HABIT-DISORGANIZATIONS 
 
 without analysis of the facts. I might furnish other instances of 
 tantrums allied to dementia prsecox developing without well- 
 marked antecedents of deficiency, and on such ground taking a 
 favorable course. 
 
 Looking over the whole field we see in dementia prsecox above 
 all the psychic deficiency to meet actuality, a tendency to unreality, 
 to the mystic, common enough outside of dementia precox, but 
 here combined with the deficiency of judgment and habit due to 
 the undermining effects of other disorganizations of mental and 
 organic habits. The prevalence of defect in the habits of the 
 reproductive zone is most striking, especially in walks of life 
 where the difficulties are less likely to be swallowed up by the 
 muddy stream of open immorality, where conventional morality 
 and frequently excessive observation of superficial morality 
 create remarkable pictures which figure very well as classical 
 representatives of the disorder. 
 
 Looking back over the merits of the point of view taken, I 
 should like to say in its favor that it tends towards putting into 
 the center of nosological and pathological attention the only fac- 
 tors which can be of practical importance in the management of 
 these disorders. 
 
 In the general discussion on the paragraphs of etiology, these 
 points of disharmonious development are put down as the product 
 of mere fatal constitutional defect, the result of some statistical 
 fate, reminding one of the dogma of infant damnation, training 
 in the students a habit of moving in generalities and fostering a 
 disinclination to going into the study of the actual case ; the age 
 at which the disease occurs, the sex, the climate, the stress, and a 
 lot of other things from which no individual can escape are re- 
 hearsed, and with a sort of disdain for the actual pathological and 
 morphological value of the directly important things, which are 
 relegated to casual remarks under therapeutics, where we find 
 warnings against masturbation, against overactivity of the artistic 
 imagination, etc. 
 
 Didactically and from the point of view of keeping one's self 
 in the frame of soundest activity, it seems to me very desirable 
 that these factors, the working factors of the disease, should be 
 utilized to the utmost ; and, in the face of the inevitable criticism 
 that these are old matters which everybody knows and that what
 
 REMARKS ON HABIT-DISORGANIZATIONS IO9 
 
 is wanted is some absolutely new discoveries, we need no longer 
 be afraid of conjuring up a moralizing psychiatry if we hold each 
 other down to speaking of the facts as they occur in actual cases, 
 and as they are not only conceivable but actually at zvork. There 
 is hardly anything of which it is not possible to say that the 
 ancient Hindoos, the Greeks and our forefathers thought exactly 
 the same way, and that we do those things in every-day life. Un- 
 fortunately, speculation too easily solves many puzzles which it 
 takes many years of experimental and clinical work to put on a 
 safe working basis. It is, nevertheless, concrete work that has to 
 be done and will prove the soundest ground for stimulating the 
 interest of the physician in his work of understanding and modify- 
 ing cases, and in forming sufficiently definite problems in what 
 otherwise would be a mess of arbitrary creations of nosology.
 
 CONSTITUTIONAL FACTORS IN THE DEMENTIA 
 
 PRECOX GROUPS 
 
 By Dr. August Hoch 
 
 PSYCHIATRIC INSTITUTE, N. Y. STATE HOSPITALS 
 
 Among the present problems of psychiatry the study of dementia 
 praecox is perhaps that which excites the most general interest. 
 It is more particularly the fundamental nature of the disorder 
 which is discussed, and in regard to which the views diverge. 
 The claim is often made that we have in dementia praecox an 
 organic brain disease similar to general paralysis or the other 
 typically organic disorders. There is no doubt that we find in the 
 central nervous system in cases of this group structural changes ; 
 some of them are evidently not related to the disorder, while there 
 are others which probably form a part of the process, although 
 we do not yet clearly understand under what conditions they are 
 found nor what their real significance is. While these findings, 
 upon which rests the claim that dementia praecox is an organic 
 disorder in the same sense as is general paralysis, cannot be 
 neglected, and represent a most important field for research, there 
 is another set of data furnished by an analysis of the constitu- 
 tional factors in these cases, of the development of the symptoms, 
 their nature, and their relationship among each other — data which 
 would seem to show that, granted all the findings of an anatomical 
 and perhaps chemical nature, dementia prsecox is after all not a 
 condition which can be placed side by side with the plainly organic 
 diseases, such as general paralysis. Instead of going into a theo- 
 retical discussion as to the possibilities of relationship between 
 functional and organic disorders, it would seem wisest, as an 
 introduction to what I have to say regarding the constitutional 
 abnormalities in dementia praecox, to put together the fundamental 
 dififerences which seem to exist between the plainly organic dis- 
 
 ^ Elaborated from a paper read at the New York Psychiatrical Society. 
 November 4, 1908. 
 
 Ill
 
 112 FACTORS IN DEMENTIA PRECOX GROUP 
 
 orders like general paralysis on the one hand, and the dementia 
 prarcox group on the other hand. 
 
 In the first place, the dementia in the plainly organic disorders 
 is different from that of dementia praecox. In the former we 
 find that the dementia represents a diffuse disorder of activisation 
 of memories — and hence gives rise to a diffuse defect of elabora- 
 tion, retention, memory, orientation, etc. In dementia praecox it 
 shows itself essentially in the sphere of interest in the environ- 
 ment, and in a peculiar distortion of the train of thought. In the 
 second place, in the organic disorders we find that the content^ of 
 the psychosis is of secondary importance, while in dementia praecox 
 the content seems to stand in the very foreground of the clinical 
 picture ; the content is, moreover, apt to be peculiarly limited, so 
 that in patients who are accessible to an analysis we find the exist- 
 ence of special trends which account for the entire content. This 
 is something which these cases of dementia praecox have in com- 
 mon with disorders such as hysteria, certain simple paranoic states 
 and some psychoses of degenerates, that is, conditions in which 
 the psychogenic nature of the symptoms is now scarcely ques- 
 tioned by anyone. It is well to remember in this connection that 
 the above mentioned states, to which we shall again have to refer 
 later, are not always easily differentiated from dementia praecox; 
 probably this difficulty exists not merely owing to our inadequate 
 diagnostic facilities, but also owing to the closer relationship which 
 these conditions bear to the disease in question. 
 
 Finally, we find that dementia praecox presents yet another side 
 which would point to a certain kinship with these psychogenic 
 disorders. I mean the fact that the relationship between the per- 
 sonality, the special mental make-up of the individual and the 
 psychosis, is a much closer one, the constitutional factors of much 
 more determining importance in the development than in the 
 organic disorders, where we often find either no appreciable pecu- 
 liarity of mental make-up, or where, at any rate, we have no rea- 
 son to think that the essential manifestations of the psychosis 
 grow, as it were, out of the personality. 
 
 ^The term content is here used in the sense in which Jung has used it 
 in his " Inhalt dti' Psychose " (Leipzig u. Wien, Franz Deuticke, igo8). 
 and therefore contrasted to the formal disorders which have received 
 more attention.
 
 FACTORS IN DEMENTIA PRECOX GROUP II3 
 
 It is obvious, therefore, that there are quite a number of impor- 
 tant considerations which show that whatever anatomical changes 
 may be found, their relationship to the disorder is evidently not 
 so simple as in those diseases which are clearly organic ; and it is 
 therefore necessary to insist that, in addition to a study of anatom- 
 ical and chemical alterations, there is a vast field of inquiry at 
 least as important and more accessible for the elucidation of the 
 nature of the disorder, namely, the study of the personality and 
 the study of the development and the content of the psychosis. 
 
 I wish to dwell in this communication upon the study of the 
 make-up only, and more particularly on the type most frequently 
 seen. It will be remembered that it was Adolf Meyer who, since 
 1903, has insisted that dementia prsecox is a disorder which may 
 not develop in anyone, but that only some personalities are in 
 danger, and that in the development inadequate psycho-biological 
 habits play an important part ( i ) . 
 
 If we succeed in obtaining accurate anamneses from which we 
 are able to form an opinion of the personality as it existed before 
 the psychosis, or before the incubation period, as it is sometimes 
 called, a certain type of personality recurs with striking frequency, 
 that which I have called the " shut-in personality" (2) the signifi- 
 cance of which I wish to discuss more particularly. We may 
 start with a few examples. 
 
 One patient, a married woman of nineteen, is said to have been quick 
 enough to learn, and to have studied much ; she was also a frequent 
 church-goer, especially since the age of sixteen, without, however, taking 
 an active part in the church work. Even before the age of five she did 
 not get on with other children, did not play with them, but was inclined 
 to keep to herself. When people came to the house she left the room ; 
 she was described as always " helpless " in company. She was not liked in 
 school, and never helped others. She was hard to influence — did not take 
 advice. She was over-systematic ; wanted things which belonged to her 
 left alone. She was sensitive and cried when interfered with, and was apt 
 not to get over the upset for days. She saw faults in others, rather than 
 her own defects ; thought she was better than her fellows, but did not assert 
 herself. She never confided in anyone. She married when eighteen, and 
 during her first pregnancy was uncommonly insistent in her desire to 
 have a boy who should not have red hair, and when it was a girl with 
 red hair she lost interest, and the psychosis at once developed. 
 
 The second patient is said, especially since the age of eight, sub- 
 sequent to an attack of measles, to have grasped her studies less well than
 
 114 FACTORS IN DEMENTIA PRECOX GROUP 
 
 before, was always self-conscious, felt awkward in company and was 
 sensitive, but she said little about it, and in general talked very little. The 
 mother says that the patient was in this respect much like her father, 
 who was, however, a successful, active man. She often sat brooding, was 
 uncommonly systematic and " finicky." At puberty the seclusiveness be- 
 came more marked. At seventeen she went to a fortune-teller, who told 
 her she would go insane, which prediction is said to have occupied her 
 mind a good deal. At eighteen she fell in love, but her love was not recip- 
 rocated. Then she began to grow absent-minded and careless, and gradu- 
 ally drifted into a deterioration. 
 
 Case 3 represents a somewhat different type, yet still with well-marked 
 traits pointing in the same direction. The patient, a woman of thirty-six, 
 who always, even as a child, was sensitive and stubborn. She often left 
 the table at the slightest provocation, was hard to guide and influence. It 
 is remembered that she herself would say that she was as immovable as a 
 post. She was married at twenty, did not find her husband congenial, 
 had a tendency to romanticism, never adapted herself to her simple life, 
 made demands upon her husband which she knew he could not meet. 
 Her circumstances as well as her inclinations isolated her. She was 
 moody. Repeatedly she got suspicions of her husband, she fell silently in 
 love with a dentist, had fancies about him, and, for several years before 
 the onset, refused to have any intercourse with her husband. She broke 
 down only at thirty-six, and deteriorated. 
 
 These cases suffice to show that we find, in dementia prsecox, 
 persons who do not have a natural tendency to be open, and to 
 get into contact with the environment, who are reticent, seclusive, 
 who cannot adapt themselves to situations, who are hard to 
 influence, often sensitive and stubborn, but the latter more in a 
 passive than in an active way. They show little interest in what 
 goes on, often do not participate in the pleasures, cares and 
 pursuits of those about them; although often sensitive they do 
 not let others know what their conflicts are ; they do not unbur- 
 den their minds, are shy, and have a tendency to live in a world 
 of fancies. This is the shut-in personality. 
 
 As I have said, this type of make-up is very common in de- 
 mentia prsecox. In a study of my older material from the 
 M'Lean Hospital, Waverly, Mass. (72 cases), I found that in 
 35 per cent, of the cases it was markedly pronounced, whereas 
 in 16 per cent, it was indicated, so that there was some evidence 
 of it in 51 per cent. When we consider that these findings refer 
 to a time when we did not especially look for these traits, these 
 figures are all the more striking. Other abnormalities of
 
 FACTORS IN DEMENTIA PRECOX GROUP I I 5 
 
 make-up were noted in 15 per cent.; the make-up was not de- 
 scribed in 9 per cent., and in 23 per cent, the claim was made 
 in the anamnesis that the patient's tendencies were " natural." 
 In my more recent material of the Woman's department at 
 Bloomingdale Hospital, N.Y., from which I excluded the cases 
 in which the facts were not accessible — a small material, to be 
 sure, amounting only to 38 cases — I found a typical shut-in 
 personality in 49 per cent, of the cases, indication of it in further 
 19 per cent., making a total of 68 per cent, altogether. 24 per 
 cent, of the cases are described as showing peculiarities of other 
 types. It is interesting that among the cases who unquestionably 
 deteriorated, the typical shut-in personality was most often seen, 
 occurring in 66 per cent. On the other hand, in the cases who 
 did not show definite deterioration, in other words, who either 
 got well or, while presenting chronic symptoms did not lose their 
 interest in the environment to any marked degree and whose 
 train of thought did not get confused — a group including cases 
 which form a transition to the simpler paranoic states — we found 
 either indications of the shut-in personality or, still more fre- 
 quently, other abnormalities of make-up, such as long-standing 
 neurasthenoid states, shallowness of emotion, lack of considera- 
 tion for the environment, or abnormal insistence on precision, 
 a tendency to day-dreaming, evidence of a poorly-balanced sexual 
 instinct; as in one case who for years had drifted into strikingly 
 fruitless love-affairs, another who showed jealousy of the hus- 
 band for years before the onset and ever since marriage. But 
 I do not propose to go into this part of the topic, as it would 
 lead me too far, and should form the theme of a more extended 
 investigation. Finally, I found only 8 per cent, in which there 
 seemed to be a normal make-up. 
 
 Zablocka (3), who studied the dementia praecox material of the 
 Ziirich clinic in regard to prognosis, found that the shut-in per- 
 sonality is seen more often in the deteriorating than in the other 
 cases. In this connection it should be remembered that the 
 group of dementia praecox in Ziirich is very large, and includes 
 many mild cases which we would not regard as dementia praecox. 
 
 Of great interest is an excellent study which Dr. Kirby (4) 
 has recently reported at the New York Academy of Medicine, in 
 which he took up about 100 cases of dementia praecox observed
 
 Il6 FACTORS IN DEMENTIA PRECOX GROUP 
 
 at the Psychiatric Institute, and found in over 50 per cent, a 
 plainly shut-in personality, and only in a small percentage an 
 apparently normal make-up. 
 
 These figures seem to me to tell the story plainly enough. 
 That all cases should show clear indications of a shut-in person- 
 ality is not to be expected. That as many as 68 per cent, pre- 
 sented evidence of it in my recent material, over 50 per cent, in 
 that of Dr. Kirby, over 50 per cent, in my older cases, and that 
 comparatively few cases show a normal make-up — ^these are data 
 which cannot be neglected. 
 
 The shut-in personality, after all, shows only the direction in 
 which the dangerous traits lie, and it is fair to assume that other 
 abnormalities which we cannot as yet clearly define may work 
 in the same direction. The lack of contact with reality may be 
 only partial, whereas the general response is fair ; or other traits 
 which seem to interfere with satisfactory contact, or which foster 
 day-dreaming or which interfere with the formation of objective 
 interests, may be of importance. Kirby has pointed out that a 
 certain shallowness of interest without a general shutting-in was 
 not rarely seen in those of his cases which did not show the 
 typical make-up. Finally, we must not forget that behind a 
 correct appearance, the result of a formal training, there may be 
 much that is not apparent in ordinary life, but which at any time 
 may under stress come to the surface. The fact that these same 
 traits are not seen in manic-depressive insanity is certainly very 
 interesting as a control. How much of it does occur in normal 
 persons is difficult to estimate. 
 
 It may not be out of place here to say that in a question of 
 the importance or the danger of certain traits, the whole bearing 
 of which we do not yet know, it is difficult to estimate the limits 
 of elasticity until sufficient strain has been exerted to test it. 
 
 We cannot help feeling that to a certain extent these char- 
 acteristics must in themselves represent a reaction to something 
 more fundamental, but evidently a reaction along a special bent 
 of the personality, and one which owing to its very nature has 
 certain cumulative tendencies. 
 
 Freud has shown us that in the neuroses we are dealing pri- 
 marily with a lack of adaptation to reality in the sexual sphere, 
 with an inadequate or faulty development of the instinct in its
 
 FACTORS IN DEMENTIA PRECOX GROUP 11/ 
 
 wider meaning, in the sense that owing to a certain fixation and 
 limitation of the interest in that sphere in childhood, and owing 
 to subsequent repression, the later free application and adaptation 
 is interfered with. This is not the place to enter into a discussion 
 of this view which Freud has expressed in his earlier writings, 
 and again very clearly in his recent Worcester lectures (5), 
 and which Jung has extensively supported by his own studies. 
 Important for us in this discussion is the fact that Jung has in- 
 sisted that a similar sort of abnormality in the sphere of the 
 sexual instinct exists in dementia praecox. While I have person- 
 ally not analyzed a sufficient material with the view of verifying 
 this claim from direct evidence, I am nevertheless inclined to 
 regard this as very probably a correct one, for the following 
 reasons : In the first place, we should mention the close relation- 
 ship which exists between dementia praecox and puberty. Sec- 
 ondly, the fact that everyone who has attempted to enter into the 
 lives and struggles of these patients must have been impressed 
 with the frequency with which sexual conflicts are found to have 
 played an important role in the development of the disorder. 
 Thirdly, analysis of the content of the psychosis shows us again 
 and again the existence of sexual trends, and often when the 
 sexuality manifests itself, it does so in a peculiarly diffuse, poorly 
 adapted manner, such as in the falling in love with several per- 
 sons at the same time, and the like. All this cannot be accidental. 
 There is, therefore, much that speaks in favor of the claim of 
 a fundamental lack of sexual adaptability ; but, according to those 
 who have analysed the neuroses of various kinds, we find there 
 similar difficulties, but without equally serious consequences. 
 
 We are scarcely prepared to say what is fundamentally the 
 nature of the lack of sexual adaptability, and what is its relation 
 to the shut-in personality. However, Abraham (6), who has 
 fully recognized the importance of the shut-in personality, has 
 attempted to answer this question. He regards the lack of sexual 
 adaptability as due to an arrest of sexual development, a per- 
 manent retention of the infantile autoerotic stage, and looks upon 
 the shut-in tendency as one of the expressions of this autoerotism. 
 This is certainly a clever hypothesis, but we cannot help feeling 
 that the question is more complicated. 
 
 But even without knowing what is the origin or the funda-
 
 Il8 FACTORS IN DEMENTIA PRECOX GROUP 
 
 mental meaning of the constitution we have described, we can 
 see, nevertheless, reasons why such a constitution should repre- 
 sent a serious menace to the mental balance of the personality. 
 
 The inability to get into contact with the environment bears 
 in itself many dangers; it prevents an active aggressive shaping 
 of the situation which is so impoi-tant for the progress of the 
 normal individual and which forestalls further conflicts ; it pre- 
 vents the corrective influences which actual experience constantly 
 furnishes, and which is gained in the mingling with people, the 
 mutual actions and reactions; it fosters the growth of unpro- 
 ductive fancies. Everyone has a certain inclination to day- 
 dreaming, but, aside from the fact that it plays a rather subsid- 
 iary role in the normal robust person, the fancies often represent 
 in them the first dim outlines of future plans, and therefore are 
 not without reference to reality, and receive their value from that 
 side; but fancies which are out of contact with reality probably 
 exert in themselves a certain fascination which progressively 
 limits objective interest. Moreover, these very tendencies make 
 the individual unfit to acquire those constructive plans and hopes, 
 not necessarily elaborated, but felt, dimly appreciated, upon which 
 the normal person lives, and which give to him the very essence 
 of his existence. There is an absence of that progressive, pros- 
 pective satisfaction which cannot be too much insisted upon as 
 necessary for the retention of mental health. The active contact 
 with the world makes, of course, more demands upon the individ- 
 ual than a life in pure fancies, towards which the path of least 
 resistance evidently leads in these patients. We see, therefore, 
 that the traits upon which we would lay most stress in the shut-in 
 personality, the lack of contact with the environment, the satis- 
 faction with fancies instead of objective interests, the lack of 
 constructive aims and aggressiveness, must have dangers in them 
 which it would be difficult to exclude as dynamic factors in the 
 development of these disorders, and we must agree with Adolf 
 Meyer when he has again and again insisted upon the importance 
 of faulty psycho-biological habits in connection with dementia 
 prsecox. 
 
 It will now be of interest to briefly review some constitutional 
 abnormalities in groups of cases which present a certain kinship 
 to dementia praecox, — I mean in hysteria, certain paranoic states.
 
 FACTORS IN DEMENTIA PRvECOX GROUP 
 
 119 
 
 and the psychoses of degenerates recently reported by Birnbaum ; 
 cases therefore in which, and this is the point I wish to emphasize 
 more particularly, deterioration does not occur. In hysteria, in 
 which disorder we have, as was above stated, according to Freud, 
 also a certain lack of sexual adaptability, we find a very different 
 sort of personality. Here there is no lack of aggressiveness, nor 
 lack of contact with the environment, nor an absence of objective 
 interest; on the contrary, we find a constant reference to the 
 persons about, a desire to be in the centre of observation; hys- 
 terical patients force us with all means at their disposal to occupy 
 ourselves with them. 
 
 In paranoic states, too, the contact with the environment is 
 plain; these persons are sensitive, and markedly concerned about 
 the rest of the world, they expect something from it, and with all 
 their suspiciousness they are not without a certain open attitude 
 in the sense of aggressiveness and a desire to seek contact. An- 
 other equally important difference between the paranoic state and 
 the condition of dementia praecox is to be found in the fact that 
 sometimes the external situation is a much more potent factor in 
 the causal constellation of the former, as is seen in the paranoia 
 quaerulans, and other paranoic states, such as those reported by 
 Gierlich (7) and Friedmann (8), or those more recently by 
 Riidin (9). 
 
 We may finally consider that interesting group of cases which 
 lately has been taken up by Birnbaum (10), the first German who 
 fully recognized the claims of the French school regarding the 
 delire des degeneres. It is interesting that these are psychoses 
 which often resemble in their mechanisms those of dementia 
 praecox, so much so that Bleuler (11), one of the investigators 
 best acquainted with the psychology of dementia praecox, has met 
 Birnbaum with the statement that the latter had not succeeded 
 in giving a differentiation beween his cases and dementia praecox. 
 To this Birnbaum has given, what I consider a satisfactory reply :' 
 there is much that separates the two groups if one considers well- 
 marked cases of either group, but it does not seem unlikely that 
 transitions occur, although plainer transitions exist between these 
 psychoses of degenerates and hysteria. 
 
 •In Centralblatt f. Nervenheilkunde und Psychiatric, 1909, p. 429, 
 although I cannot by any means agree with his entire position.
 
 I20 FACTORS IN DEMENTIA PRECOX GROUP 
 
 In the group which Birnbaum has described we find individ- 
 uals with criminal tendencies who, under the influence of punish- 
 ment, imprisonment, frustrated escapes, denials of pardon, 
 announcement of a new indictment, etc., developed psychoses with 
 delusions, hallucinations, and other symptoms in which the ele- 
 ment of wish-fulfilment takes a very prominent and easily recog- 
 nized place. The disorder, then, depends strikingly upon external 
 difficulties and often disappears with the removal of the latter. 
 As to the make-up, these personalities, besides presenting criminal 
 tendencies, are unstable, without much determination or depth 
 of feeling, though with a tendency to outbursts of feelings ; they 
 are fickle, frivolous, unable to stick to any occupation, suggestible, 
 imaginative, eccentric, given to fantastic schemes, untruthful. 
 These patients, then, do not show a lack of contact with the en- 
 vironment, they even present a certain ill-directed aggressiveness. 
 They are, therefore, in many ways different from individuals 
 with a shut-in personality. In another point they differ, namely, 
 in the fact that their conflicts are on the surface; they are in a 
 scrape, to put it tersely, and the content of the psychosis is a 
 reaction to the scrape. Hence the make-up as well as the situa- 
 tion differs from that of dementia prsecox, although the mechan- 
 isms are, as we said, often not unlike those seen in dementia 
 prsecox. 
 
 This putting side by side of the constitutional traits of hysteria, 
 paranoic states, and certain psychoses of degenerates on the one, 
 and dementia praecox on the other hand ; this contrast of groups 
 of cases which show no tendency to deterioration with a group 
 of cases in which deterioration is an important feature, seemed 
 to me to be of value, because it can hardly be regarded as acci- 
 dental that those who deteriorate show original defects in the 
 direction which we have indicated, while those who do not dete- 
 riorate are singularly free from those very traits ; nor is the prom- 
 inence of external factors in paranoic states and in the degene- 
 rates, in contradistinction to the essentially internal conflicts in 
 dementia praecox, likely to be accidental and without bearing on 
 the question of the outcome. 
 
 Having then shown the prevalence of the shut-in personality 
 in dementia prsecox, and its absence in the non-deteriorating cases,
 
 FACTORS IN DEMENTIA PRECOX GROUP 121 
 
 it is left for us to point out certain relationships between the traits 
 we have brought out and the symptom pictures early and late. 
 
 In the first place, it is well known that the incubation period, 
 if we may be allowed the term — a period that often lasts several 
 years — is almost always marked by an accentuation of the 
 shut-in traits, the patient gets further away from the environ- 
 ment. Secondly, we can scarcely help seeing the close relation- 
 ship which exists between the constitutional traits and the nega- 
 tivism, and last, but not least, between these traits and the final 
 deterioration. What is, after all, the deterioration in dementia 
 praecox if not the expression of the constitutional tendencies in 
 their extreme form, a shutting-out of the outside world, a de- 
 terioration of interests in the environment, a living in a world 
 apart ? 
 
 All these considerations will, I hope, make clear that the con- 
 stitutional abnormalities which we have described, and which in 
 their most marked form probably represent the direction in which 
 the important traits lie, must be the expression of dynamic forces 
 of great importance. 
 
 References 
 
 1. Adolf Meyer. An Attempt at Analysis of the Neurotic Constitution, 
 Amer. Journ. of Psychol., Vol. XIV, pp. 90-103, 1903. Also Fundamental 
 Conceptions of Dementia praecox, British Medical Journal, Sept. 20, 1906; 
 The Dynamic Interpretation of Dementia Praecox, Amer. Journ. of 
 Psychol., July 1910, Vol. XXI, pp. 385-403. 
 
 2. Hoch. A Study of the Mental Make-up in the Functional Psychoses. 
 Abstract of paper read before the New York Psychiatrical Society, Nov. 4, 
 1908. Journ. of Nervous and Mental Disease, April, 1909, Vol. XXXVI, 
 p. 230. 
 
 3. Zablocka. Zur Prognosestellung der Dementia Praecox, Allgemeine 
 Zeitschr. f. Psychiatric, Vol. LXXV, pp. 318-339. 
 
 4. Not published. 
 
 5. Freud. Drei Abhandlungen zur Sexualtheorie, and Uber Psycho- 
 analyse. Franz Deuticke, Wien, 1910. This Monograph Series. No. 7 
 in Translation. 
 
 6. Abraham. Die psychosexuellen Differenzen der Hysteric und der 
 Dementia Praecox, Centralblatt f. Nervenheilkunde und Psychiatric, July, 
 1908. 
 
 7. Gierlich. t)ber periodische Paranoia und die Entstehung der para- 
 noiden Wahnideen, Arch. f. Psychiatric, Vol. I, pp. 19-40, 1905. 
 
 8. Fricdmann. Beitrage zur Lehre von der Paranoia, Monatsschr. f. 
 Psychiatric und Neurologic, Vol. XVII, pp. 468, 532. 
 
 These two translated in this Monograph Series No. 2.
 
 122 FACTORS IN DEMENTIA PRECOX GROUP 
 
 9. Riidin. t)ber die klinischen Formen der Seelenstorungen bei zu 
 lebenslanglicher Zuchthausstrafe Verurteilten. Miinchen, 1909. Review 
 Centralblatt fiir Nervenheilkunde und Psychiatric, 1909, p. 292. 
 
 10. Birnbaum. Psychosen mit Wahnbildung und wahnhafte Einbild- 
 ungen bei Degenerativen. Carl Marhold, Halle, 1908. 
 
 11. Bleuler. Wahnhafte Einbildungen der Degenerierten, Centralblatt 
 f. Psychiatrie u. Neurologic, 1909, pp. 77-80.
 
 COMPARATIVE PSYCHOLOGICAL STUDIES OF THE 
 
 MENTAL CAPACITY IN CASES OF DEMENTIA 
 
 PRECOX AND ALCOHOLIC INSANITY^ 
 
 By Henry A. Cotton, M.D., 
 
 MEDICAL DIRECTOR, NEW JERSEY STATE HOSPITAL AT TRENTON 
 
 (From the Psychological Laboratory of the Royal Psychiatric Clinic at 
 Munich. Professor Kraepelin, Director) 
 
 Scope and Object of the Investigation 
 
 The work of the investigators in the field of experimental 
 psychology in recent years has shown remarkable progress, so 
 that new light has been shed upon a great many obscure and com- 
 plicated problems connected with our mental life. 
 
 Mere speculation as to the mechanism of fundamental psychical 
 processes has given place to some extent to more accurate knowl- 
 edge of these problems, so that today many obscure and compli- 
 cated reactions can be graphically demonstrated and these same 
 processes spoken of in terms of mechanical values and equivalents. 
 To reduce these complicated processes to figures and curves has 
 been a stupendous task in the field of normal psychology, and 
 much remains to be accomplished before we can have an accurate 
 idea of all psychical phenomena. 
 
 That the experiments with normal individuals have not been 
 entirely successful is due partly to a lack of methods, and partly 
 to defects in some of the methods devised. If this be true of the 
 field of normal psychology, then we cannot wonder that investi- 
 gators in the field of abnormal psychology have experienced great 
 difficulties in representing by graphic methods the complicated 
 abnormal psychical processes in the insane. 
 
 The effects of drugs and poisons upon the psychical processes 
 have been graphically shown by Kraepelin and his pupils, and 
 their work has been of immense importance in paving the way 
 
 ^Read before the New York Psychiatrical Society. 
 
 123
 
 124 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 for a better understanding of abnormal psychological phenomena. 
 But experiments with normal individuals do not present such 
 obstacles as we find when we attempt to analyze abnormal psy- 
 chical processes of the insane by similar methods. The normal 
 processes with and without the eflfect of the poisons can be care- 
 fully analyzed and compared in the same individual, whereas, in 
 the experiments in abnormal psychology, we must compare sim- 
 ilar experiments upon normal individuals with the results in 
 abnormal individuals or the insane. 
 
 Methods that are readily adapted to the normal individual 
 become useless when applied to investigations of abnormal mental 
 conditions as found in the insane. Either the patients absolutely 
 refuse to perform the experiments, or only partially fulfill the 
 conditions, and the figures and results of such experiments are 
 not comparable with similar experiments with the normal. And 
 such figures seldom give an accurate and clear picture of the 
 pathological mental condition. 
 
 We have studied the various clinical symptoms of the insane, 
 and we know that certain symptoms refer to disturbances of cer- 
 tain psychical fields. The problem of experimental psychology 
 is to measure these abnormal reactions and compare the results 
 of such measurements with those obtained in normal psychical 
 processes. 
 
 For many years Kraepelin has searched for simple methods 
 which were suitable for abnormal as well as normal persons, and 
 he and his pupils have been successful in finding methods that 
 on the one hand were suitable for studying the psychical processes 
 of normal persons, while on the other hand, they were adaptable 
 to abnormal psychical processes as well. 
 
 His method of continuous addition of single numbers was first 
 used in experiments with normal individuals, and occupied two 
 hours a day continuously for its completion. By this simple 
 method he succeeded in graphically representing some very im- 
 portant psychical processes, and also the relation of various 
 processes to each other, i. e., fatigue — the effect of the rest or 
 pause during addition, in which recuperation takes place; the 
 effect of stimulation; the impulse and intensity of the will, and 
 variations in the will ; and the increase of actual work done 
 through practice and familiarity with the work. Kraepelin has
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 12$ 
 
 shown this in his monograph on the " Arbeitscurve,"^ and in one 
 chart all these various processes are plotted, and can be graphically 
 compared. Kraepelin admits that it took ten years of experi- 
 menting with normal individuals before he could interpret all 
 the facts shown by the " Arbeitscurve." Gradually Kraepelin 
 shortened the time from two hours to one hour, then half an 
 hour, until finally the experiment was reduced to ten minutes. 
 It was soon apparent that two hours continuous addition was 
 very fatiguing to a normal individual and wholly unsuited to 
 abnormal ones. 
 
 Through a series of experiments extending over these ten years 
 it was found that the length of time in the various experiments 
 had little to do with the relation of the various phenomena; that 
 certain laws were uniform, whether the experiment was for two 
 hours or ten minutes, and that the relation of these phenomena 
 were shown to be constant. 
 
 The method used in investigations by the author of this paper 
 is practically the original method reduced to ten minutes work 
 and simplified. And in spite of the simplicity and crudeness of 
 the method, it has been used with success to show at least some 
 of the abnormal psychical processes of the insane. 
 
 The object of this work was to investigate two forms of psy- 
 choses by this method, i. e., dementia praecox and alcoholic psy- 
 choses, and to compare the results obtained, with the results of the 
 experiments on normal individuals of the same station in life and 
 grade of intelligence. The method is simply a continuous addition 
 of single numbers. These numbers are placed in long columns, 
 and the task of the patient is to add consecutive numbers together 
 and place the result opposite these numbers. This continues for 
 ten minutes, and at the end of each minute, by a signal, the 
 patient makes a line to indicate the same. The experiment lasts 
 ten days. On alternate days a five minutes' pause or rest is given, 
 and on other days the patient adds for ten minutes without any 
 pause or rest. Then the number of additions during each minute 
 is taken as units of the curve. Experience has shown that the 
 amount of time lost in writing the result is very small, and 
 extends uniformly over the entire experiment, and need not be 
 
 ' Die Arbeitscurve, Emil Kraepelin, Leipzig, 1902.
 
 126 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 taken into account, also, that mistakes made need not be con- 
 sidered, as the task is so simple that any one who has a rudi- 
 mentary education in arithmetic can undertake the experiment. 
 
 This investigation was begun in the Psychological Laboratory 
 of the Royal Psychiatric Clinic in Munich in the spring of 1906. 
 The patients for investigation were partly from the Psychiatric 
 Clinic in Munich, and partly from the District Insane Hospital at 
 Egelfing, in the vicinity of Munich. The experiment with the 
 patients is a comparatively simple matter, but calculating the 
 results and interpreting the same is extremely difficult, and to 
 Professor Kraepelin should be given the credit for a large share 
 of the work, for without his assistance in interpreting the results 
 the experiment would have been worthless. 
 
 We have investigated altogether fourteen cases of alcoholic 
 psychoses, among which were several cases of delirium tremens, 
 alcoholic hallucinosis, and chronic alcoholic insanity. Also twelve 
 patients with dementia praecox who were in the first stage of the 
 disease, mostly the catatonic form. The figures for the normal 
 were taken from the work of Drs. Plaut and Rehm of the Psy- 
 chiatric Clinic in Munich, who investigated these normal cases 
 in conjunction with similar work with manic depressive insanity 
 and psychasthenia. 
 
 I am indebted to these men for furnishing me with figures of 
 normal people, and for their assistance in preparing this work. 
 I wish also to express my thanks for the courtesy of the assist- 
 ants in the Clinic of Munich, as well as the assistants in the Dis- 
 trict Insane Hospital at Egelfing, who rendered much aid in 
 providing suitable patients for these studies. 
 
 The Method in Detail 
 
 As we have mentioned before, the method consists in adding 
 single figures together and placing the sum opposite the printed 
 numbers. Thus, a page of printed figures is before the patient, 
 arranged in long columns, about 50 figures to a column. 
 
 These experiments are performed every day for 10 days. On 
 alternate days a rest of five minutes is allowed, so that the rest 
 is indicated by a dotted line between the fifth and sixth minute 
 (see Fig. i).
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 127 
 
 Thus 
 
 , — 
 
 8 
 
 
 9 
 
 17 
 
 3 
 
 12 
 
 4 
 
 7 
 
 6 
 
 10 
 
 2 
 
 8 
 
 S 
 
 7 
 
 the left hand figures being the printed figures, and the 
 right hand figures the additions of consecutive numbers. 
 A stop watch is held by the investigator, and at the 
 end of every minute the patient is told to "mark," 
 which he does, and goes on adding until the 10 minutes 
 are finished. 
 
 The curves shown in Fig. i, are made up as follows: The 
 abscissa represent the minutes of work from i to 10, and the 
 ordinate represents the total number of additions performed in 
 each minute. The curve on the left "without pause," is made 
 from the work on alternate days, first, third, fifth, etc., days, and 
 the curve on the right " with pause," is made up from the work 
 on the second, fourth, sixth, etc., days. These curves represent 
 the average of each five days' work. To illustrate, one example 
 of the work done on normal persons by Wilhelm Specht. Below 
 are given the numbers for each minute in the ten days' inves- 
 tigation. 
 
 I 
 
 . 
 
 63 
 
 54 
 
 56 
 
 52 
 
 58 
 
 56 
 
 53 
 
 52 
 
 54 
 
 52 
 
 284 
 
 266 
 
 3 
 
 . 
 
 75 
 
 66 
 
 69 
 
 67 
 
 64 
 
 68 
 
 68 
 
 66 
 
 68 
 
 62 
 
 344 
 
 329 
 
 5- 
 
 7- 
 
 73 
 
 69 
 
 75 
 
 71 
 
 66 
 
 70 
 
 69 
 
 67 
 
 70 
 
 70 
 
 68 
 
 72 
 
 73 
 
 68 
 
 73 
 
 356 
 
 338 
 
 360 
 
 73 
 71 
 72 
 
 74 
 70 
 
 360 
 
 9 
 
 . 
 
 78 
 
 75 
 
 73 
 
 71 
 
 75 
 
 66 
 
 73 
 
 66 
 
 71 
 
 65 
 
 370 
 
 343 
 
 2 
 
 48 
 
 61 
 
 44 
 
 55 
 
 43 
 
 51 
 
 44 
 
 47 
 
 44 
 
 50 
 
 223 
 
 264 
 
 i 
 
 \ 
 
 72 
 
 69 
 
 64 
 
 66 
 
 57 
 
 66 
 
 63 
 
 64 
 
 59 
 
 64 
 
 315 
 
 329 
 
 6 
 
 73 
 
 76 
 
 67 
 
 72 
 
 70 
 
 70 
 
 67 
 
 69 
 
 68 
 
 69 
 
 345 
 
 356 
 
 8 
 
 77 
 
 80 
 
 74 
 
 72 
 
 74 
 
 67 
 
 70 
 
 70 
 
 70 
 
 70 
 
 365 
 
 359 
 
 10 
 
 74 
 
 76 
 
 74 
 
 75 
 
 75 
 
 74 
 
 73 
 
 72 
 
 72 
 
 74 
 
 368 
 
 371 
 
 In the above table the vertical figures represent the number of 
 additions in minutes, the first five minutes on the left of the 
 vertical line, and the second five minutes on the right, and the 
 successive days, as explained above. The average of these daily 
 figures is shown in the two curves — in Fig, i we see in curve h 
 (with pause) that there is a decided downward course of the 
 curve, showing a drop from 42.5 to 38.7 at the end of the fifth 
 minute. The cause of this sinking of the curve is due principally
 
 128 
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 to fatigue (mental) as the mental work progresses. But there is 
 another factor to be considered, and that is practice. For prac- 
 tice without fatigue would show an increase in the amount of 
 work done, and the curve would rise instead of falling. But the 
 fatigue overbalances the practice and consequently the curve sinks. 
 After a five minutes pause, it will be noticed that the work 
 
 ^ro 
 
 
 
 ¥10 
 
 
 A 
 
 430 
 
 \ 
 
 /\ 
 
 «vo 
 
 \ 
 
 \ * \ 
 
 <^/o 
 
 ^*-*^/^^v 
 
 \ ' \ 
 
 tfO^ 
 
 v^ 
 
 v. 1 \y^ 
 
 S9c 
 
 'V 
 
 ^*"~^ 
 
 iro 
 
 • • 
 
 
 / I s V r c 7 i f ^c f 1, ) V r c ? i 9 ^* 
 
 a b 
 
 Fig. I. 
 
 done in the sixth minute is not only much greater in amount than 
 at the fifth minute (directly before the pause), but is also larger 
 than the amount done at the beginning of the experiment, and 
 consequently we find the curve beginning almost at 44 instead of 
 42 the first minute. 
 
 This increase in the amount of work done the sixth minute is 
 explained by two facts which have taken place during the five 
 minutes' rest or pause. In the first place the fatigue has been 
 overcome by recuperation, and the person starts out freshened 
 and ready to work. At the same time the effect of the practice 
 of the first five minutes has some value in the amount of work 
 done, being more than in the first minute. It is true that during 
 the pause or rest, the practice has to a small degree lost its 
 effect, but the disappearance of fatigue also must be considered 
 in explaining the larger value of the work in the sixth minute. 
 Especially is this seen in comparing the work of the sixth minute 
 in curve a. Here the value is 41 against 44 for the same minute 
 after a pause of five minutes. The work of the entire five min- 
 utes after the rest is much greater than the work of the first five 
 minutes. Hence, we must ascribe the increase largely to the 
 effect of recuperation during the rest, and the loss of fatigue.
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 1 29 
 
 From Table I we get the following values : The numbers on the 
 left side of the line are the values of the fifth minute before the 
 pause for five days. On the right side of the line are the values 
 for the sixth minute following the pause for five days. The sum 
 of these separate columns gives the total amount of work done 
 in the fifth and sixth minute, with an intervening pause. 
 
 44 
 
 61 
 
 59 
 
 69 
 
 68 
 
 1<> 
 
 70 
 
 80 
 
 72 
 
 76 
 
 313 
 
 362 
 
 1 1.5 per cent, increase after the rest. 
 
 Here is shown distinctly the effect of the pause or rest in the 
 II. 5 per cent, increase in work done in the sixth minute over 
 that done in the fifth minute before the pause. When we com- 
 pare the work done in the fifth and sixth minutes on the days 
 with the pause with the same minutes on the days without the 
 pause, we see in curve a that the fifth and sixth minutes are 
 practically the same, that no increase can be noticed as compared 
 with curve h. For the fatigue has been compensated in the latter, 
 but not in the former instance. The curve shows in general a 
 descending tendency due, as we stated above, to the overbalancing 
 of the fatigue over the practice, but the fifth and sixth minutes 
 are at the same level. The slight rise of the curve at the fifth 
 minute is not due to a balance between the fatigue and practice, 
 but to the effect of the tension, or straining of the will, which 
 overcomes the fatigue. And the straining of the will frequently 
 shows itself in the curves and is considered an impulse of the 
 will to overcome the fatigue. This impulse is effective in keep- 
 ing the amount done in the fifth and sixth minute at the same 
 level. Without this straining of the will in the course of the 
 work, both values of the fifth and sixth minutes would be much 
 smaller and the curve would descend at this point as a result of 
 fatigue. So that 11.5 per cent, increase after the pause stands 
 for the direct effect of the pause, when taken with the percentage 
 of increase on the days without the pause, thus: 
 
 1 1.5 per cent, increase after pause. 
 0.0 per cent, increase without pause. 
 
 ii.S per cent, increase after pause, or direct effect of pause. 
 10
 
 130 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 We must also consider the total amount of work done before 
 the pause and after the pause or the total work of the first five 
 minutes must be compared with the total work of the five min- 
 utes after the pause, and also compare these percentages with 
 those obtained in the same manner by comparing the same values 
 of the days without a pause. 
 
 From the table we get the following figures, the left hand 
 column representing the total work of the first five minutes for 
 five days, and on the right side, the total work of the last five 
 minutes after the pause. 
 
 223 
 
 264 
 
 315 
 
 329 
 
 345 
 
 356 
 
 36s 
 
 359 
 
 368 
 
 371 
 
 1,616 1,679 = 3-3 per cent, increase of total work after the pause. 
 
 This increase after the pause is explained by the effect of the 
 practice, a portion of which remains even during the rest, and 
 therefore more work is accomplished in the last five minutes, 
 although the fatigue also plays a part as shown by the descend- 
 ing curve. When we assume that during the pause the fatigue 
 has been entirely recuperated by the rest, then the increase in 
 work after the pause represents the practice coefficient of the 
 individual. 
 
 Under what conditions, and in what manner the fatigue is 
 compensated during the pause, at present we are unable to state. 
 
 Through the increase of the work after the pause, although 
 a certain residual of fatigue is present, we must conclude that 
 the practice has overcome to some extent the fatigue. The 
 residual can be great, and at the same time hidden by the effect 
 of practice when the latter is sufficiently great. And we can also 
 conclude that possibly during the rest or pause, that the fatigue is 
 entirely compensated, and no residual remains, and that the effect 
 of practice is very small. 
 
 To come to a definite conclusion in regard to this question, we 
 must first compare the work equivalents of the days when no rest 
 was taken, and where consequently the effect of the rest does not 
 come into play. From the table we again take the following
 
 MENTAL CAPACITY IN DEMENTIA PRECOX I3I 
 
 figures. The figures on the left represent the total work of the 
 first five minutes for five days, and on the right of the column^ 
 the total work for the last five minutes for five days. 
 
 284 
 
 366 
 
 344 
 
 329 
 
 356 
 
 338 
 
 360 
 
 300 
 
 370 
 
 343 
 
 1,714 
 
 1,636 = 4.1 per cent, decrease in last five minutes over first five 
 
 
 minutes. 
 
 In other words, without the good effect of the rest, the fatigue 
 shows itself, and the work fell off 4.1 per cent. But from this 
 coefficient alone we cannot compute the effect of fatigue. In 
 the second five minutes work the fatigue overcomes everything 
 else, but we cannot tell to what extent the total amount of work 
 has been influenced by the simultaneous opposing effect of the 
 practice. 
 
 It is possible that the decrease of the work in the second five 
 minutes might be much less, if the individual was capable of 
 improving by practice. We get an idea of the importance of the 
 fatigue when we compare the differences in the total amount of 
 work done after the pause and without the pause. 
 
 That the work of the second five minutes on the days without 
 and with a pause or rest, approach each other as regards the 
 effect of practice, can be shown. However, where recuperation of 
 the fatigue during the pause has taken place, the comparison of 
 days without any rest (where the second five minutes is under the 
 influence of the fatigue) and the days with rest, the difference 
 in the two series will give us the value of the fatigue. This dif- 
 ference is shown below. 
 
 3.3 per cent, increase in total work after pause. 
 4.1 per cent, increase in total work last five minutes, 
 
 7.4 per cent, coefficient of fatigue. 
 
 For computing the individual fatigue we make use of two 
 groups of figures obtained by this method from the same indi- 
 vidual. On one hand the relation of work values of the fifth and 
 sixth minutes, and on the other hand, the difference in the total
 
 132 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 amount of work done in the first and second five minutes on the 
 days with and without pause. We will see later, when discussing 
 fatigue in our three groups, how the coefficient of fatigue is 
 vastly different in dementia prsecox from normal individuals and 
 alcoholics. 
 
 Comparison of Individual Work Curves 
 
 In Fig. 2 we have shown a typical curve from the groups in- 
 vestigated and compared with a normal curve.^ 
 
 The curves on the left each represent the average of five days 
 work for ten minutes per day uninterrupted. The curves on the 
 right represent the average of five days work with a pause of 
 five minutes after the fifth minute of work. This period is rep- 
 resented by the dotted line. The curve of the following five 
 minutes represents work after the pause. 
 
 In the normal curve a-/ it will be seen that there is a gradual 
 tendency of the curve to descend, although in places it appears 
 almost horizontal. However, the values do show that there is a 
 decrease in amount of work done in successive minutes, but in 
 tenths so that it cannot be accurately shown in the curve. There 
 is a certain regularity to the curve, when compared to that of 
 dementia prascox. Also in curve a^II (normal), the effect of the 
 pause is distinctly shown, for after the pause, presented by the 
 dotted line, the curve begins at a much higher point than the fifth 
 minute, and a trifle higher than the beginning of the curve. This 
 curve also shows the gradual decline in the amount of work done, 
 both before the pause and after the pause, although the entire 
 curve after the pause is distinctly higher than the curve of the 
 first five minutes. As we said above, this is due to the loss of 
 fatigue during the rest, and also to the residual practice, which 
 has shown itself in the period following the rest. 
 
 Comparing this curve of a normal individual with curve b, that 
 of a dementia praecox case, the difference between the two is at 
 once apparent. In the first place one sees tremendous variations 
 in the curve b-L The curve sinks very low at the fifth minute, 
 
 ' Curve taken from figures of a normal person given by Wilhelm Specht 
 in Uber klinische Ermiidungsmessungen, Archiv fiir die Gesamte Psy- 
 chologie, Band III, Heft 3.
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 133 
 
 then rises again and ends much higher. This can only be ac- 
 counted for by the variations in the intensity and impulse of the 
 will, of which we will speak more in detail later. When we 
 observe the curve b-II, representing the period with a rest, we 
 
 Fig. 2. 
 
 see that instead of the sixth minute rising distinctly above the 
 fifth minute (before pause) the curve starts at a much lower 
 level. This shows that the rest has not had a good effect upon 
 the work of the patient, but has had a decidedly unfavorable
 
 134 MENTAL CAPACITY IN DEMENTIA PR/ECOX 
 
 influence on the after work. It also shows that there was either 
 no fatigue present or that if present, it was not compensated dur- 
 ing the pause. And from what we know clinically of dementia 
 prsecox cases, especially the catatonic forms, the first supposition 
 is the correct one. The sinking of the curve, then, is not due to 
 fatigue, but to fluctuation and variations in the intensity of the 
 will ; although apparently working steadily along, the curve shows 
 that the will is far from being under the control of the patient. 
 In curve C-I and //, that of a patient with alcoholic hallucinosis, 
 we find very little deviation from the normal. The fatigue is 
 shown by the gradual descent of the curve. And after the pause 
 or rest, the curve begins at a much higher level, not only as com- 
 pared with the fifth minute, but with the first minute as well. 
 While these curves are shown as typical of the three groups under 
 discussion, it must not be supposed that all of the cases in the 
 three groups would show similar curves respectively in each 
 group. There are wide variations in individuals of the three 
 groups, but at the same time the average of the curves of each of 
 the three groups will show distinct differences from each separate 
 group. Especially will this be shown later when different fac- 
 tors are considered, such as fatigue, impulse of the will, daily 
 increase in work, total amount of work done, etc. 
 
 Combined Average Work Curves (Fig. 3) 
 
 An effort was made to show the average curve of each group, 
 but the results of averaging all the curves of one group was not 
 a representative curve, as the variations of each individual curve 
 would balance that of the others of the same group, and the 
 result was not a representative curve. But this difficulty was 
 overcome by Professor Kraepelin, when he suggested curves made 
 up of the relation of each minute to the first minute, without any 
 reference to actual values. So the combined work curves were 
 constructed as shown in Fig. 3. Here the peculiarities of each 
 group were represented graphically, and the result was startling. 
 The work of the first minute in each group is the basis for com- 
 puting the proportion of every other minute to the first. The 
 standard value of the first minute is placed at 100. The value of 
 the other minutes are computed by logarithms in terms of the first
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 135 
 
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 136 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 minute, or 100. Thus, in the normal curve, constructed from 
 the average proportion of the 25 individuals, shows the second 
 minute to be 92.4, in other words, the relation of the average of 
 the first minute to the relation of the average of the second min- 
 ute of all individuals, is as 100 to 92.4, and so on for the rest of 
 the curve. And the same method was used for the other two 
 groups. It will be noticed that at the fifth minute the curve di- 
 vides, one curve continues on, and the other is represented by a 
 dotted line. This division of the curve is to show the difference 
 in the relations of the last five minutes without a pause (the 
 uninterrupted line), and the last five minutes following the pause 
 or rest, as shown by the dotted line. The first five minutes of 
 each day is taken, as the work is uniform until the end of the 
 fifth minute, when on one day a pause intervenes, and on alter- 
 nate days no pause is allowed. In other words, the first five 
 minutes of all curves of an individual group are obtained under 
 similar conditions, while after the fifth minute, the pause makes 
 a distinction. And the effect of the pause is graphically shown 
 by the curve represented by the dotted line. In the normal it 
 will be seen that the curve gradually descends, although there are 
 some slight variations throughout the ten minutes work without 
 a pause. (Note the abscissa indicates the minute of work, the 
 ordinate the proportions of each minute to the first minute.) The 
 sixth minute (dotted line) is separated from the sixth minute 
 (straight line) by a considerable space. In the former the value 
 is 97, in the latter 88. This difference represents the direct effect 
 of the pause, and it will be noted that the course of the curve 
 (dotted line) continues at a much higher level than the other 
 curve. This corresponds with the typical normal curve in Fig. i. 
 Another peculiarity is that in the last two minutes of the lower 
 curve there is a slight rise, showing the effect of the straining 
 of the will by a distinct effect to overcome the fatigue. As the 
 fatigue after the pause is less, we do not have this strain at the 
 last, and the curve sinks during the last minute of work. 
 
 The difference between the values of the first and second minute 
 represents the impulse of the will (Antrieb). As we all know, 
 when one has a certain task to perform one goes at it with a 
 strong impulse to accomplish the task, and this tension, as soon 
 as the work is started, lets up, and the second minute shows a
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 1 3/ 
 
 considerable decrease in the amount of work done as compared 
 with the first minute, or at the beginning of the task. And the 
 difference between the sixth and seventh minute after the pause 
 (dotted Hne) represents the impulse of the will after the pause. 
 This is not so great as the impulse at the beginning, as through 
 practice the task is known, and one does not strain the will to 
 accomplish the work at hand to such an extent as first. 
 
 When we observe the combined curve of the dementia praecox 
 cases, we at once notice a marked contrast with the normal. The 
 same variations and fluctuations in the curve are seen as were seen 
 in the typical curve of dementia praecox in Fig. i, b. But this is 
 a composite curve of the twelve cases of dementia praecox, and 
 the variations would be lessened rather than increased. One point 
 of difference between this and the normal curve is the sudden 
 sinking of the curve from the fourth to the fifth minute. Here 
 is a drop from 96.5 to 84 and then a sudden rise to 93 at the sixth 
 minute. As seen by the fluctuations, the question of fatigue does 
 not come into consideration at all. First, because there are two 
 ascents to the curve following this, and secondly, because the sixth 
 minute after pause is comparatively very little above the sixth 
 minute without any pause. 
 
 To find the explanation, then, we must consider the will which 
 is seriously affected in dementia praecox. Here the defect is 
 graphically demonstrated, and the sudden descent of the curve 
 can be ascribed to the neglect of the will (Vernachlassigung des 
 Willens) or deflection of the will. 
 
 The fluctuations of the curve in the last five minutes (without 
 pause) is remarkable and is explained by the difficulty of keeping 
 dementia praecox cases at a given task. The apathy shown clin- 
 ically is here graphically demonstrated. 
 
 The course of the curve after the pause (dotted lines) also 
 bears out the statement that there is little fatigue, and the curve, 
 instead of remaining at a higher level after the pause, actually 
 sinks lower than the continuous curve. So that from this curve 
 three facts are demonstrated: (i) The absence of fatigue, (2) the 
 irregularity of the tension of the will, (3) the absolute deflection 
 of the will. The impulse of the will at the onset of the work is 
 much less than in the normal and much less than that in alcoholics. 
 The third curve represents the composite curve of the alcoholics.
 
 138 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 This type of patients investigated were variable, and some -were 
 practically normal, especially those recovering from delirium 
 tremens. The others belonged to the class of alcoholic halluci- 
 nosis and alcoholic paranoic conditions. 
 
 This curve does not differ materially from the normal, except 
 in the height of the curve at the sixth minute after the pause. 
 Here the curve starts at 103 or 3 points above the height at the 
 beginning of the work and six points above the same value in 
 the normal curve. 
 
 This increase in the amount of work done in the sixth minute 
 in alcoholics over the normal is explained, not so much by the 
 fatigue, but by the fact that during the pause the residual idea of 
 the work is lost, and they start in with a marked tension of the 
 will, assisted by the residual practice-effect (Ubungs Nachwirk- 
 ung). And they seem to have lost the impression of the work 
 during the pause, so that it is in one sense a new task to them, 
 while in the normal the memory impression is more lasting, and 
 the normal does not start out with such a great impulse to accom- 
 plish the task. 
 
 Total Mental Capacity 
 (Absolute Leistung) 
 
 We obtain the values for the total capacity for mental work or 
 the absolute ability for work in the various groups, by taking an 
 average of the total number of additions performed in the first 
 five minutes for the ten days. It is impossible to take the average 
 of the whole ten minutes for on alternate days a rest or pause is 
 allowed after the fifth minute, and consequently the last five min- 
 utes of work cannot be used in computing the amount of work 
 performed by the individuals of the various groups. 
 
 By observing Chart I we will see the values for the total mental 
 capacity represented in a graphic manner. The values are repre- 
 sented by columns for comparison, and it will be seen that there 
 is very little difference in the amount of work done by the three 
 groups. The values for the normal group vary from 263 to 104, 
 and the average for the group is 185. In the dementia praecox 
 group the variations are between wider limits, i. e., from 289 to 
 92, but the average is considerably lower than in the case of the 
 normal group, viz., 165.
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 1 39 
 
 In the alcoholic group the variations are between much wider 
 limits, i. e., from 323 to 96, and the average for the group is i88, 
 a trifle higher than the normal average, while the average for the 
 dementia praecox group is much below that of the normal and 
 alcoholic groups. One is at first surprised that the difference is 
 so slight. But when we consider the clinical features of dementia 
 praecox, this finding is not so surprising, and the clinical and psy- 
 chological facts are in harmony. We know that frequently in 
 this class of cases the intellectual defects are slight, and often 
 absent for many years, so that the patients afflicted with this dis- 
 ease retain to a considerable degree their intellectual faculties, 
 although profound disturbance of other psychic fields (emotion, 
 will and ideation) are present and prevent the patient from living 
 a normal mental life. 
 
 We will demonstrate later that the disturbance in dementia 
 praecox is to be found in other fields than the purely intellectual. 
 Of course, in the end stages of the disease this field also suffers 
 and we see cases with profound mental deterioration. The 
 alcoholic group exhibited only slight deviations from the normal, 
 and none of the cases were demented so that the intellectual 
 capacity does not differ materially from the normal. So this fact 
 is in absolute harmony with the clinical symptoms of the disease. 
 
 In connection with the total intellectual capacity we must con- 
 sider the daily increase in the amount of work performed through 
 practice (Ubung). This is shown, first, in Chart I, now under 
 consideration, and is represented by the lined columns at the base 
 of the solid block columns. This is illustrated in this manner so 
 that one can compare the daily increase with total capacity in indi- 
 vidual cases of the three groups. And the figures given in the 
 squares represent the values of the daily increase in each case. 
 The values are shown graphically again in Chart 2 for a com- 
 parison of the three groups. 
 
 By comparing the values in Chart i it will be seen that there is 
 considerable variation between the amount of work performed, 
 and the daily increase through practice in different individuals. 
 Thus, in the normal group the highest daily increase ( 14) occurs 
 in two cases, in one where the total work value is 180, somewhat 
 below the average, and in the other with a total work value of
 
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 142 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 230, somewhat above the average of 185. The variations, how- 
 ever, are not so marked as in the dementia prsecox and alcoholic 
 groups. In the normal the average for the first 14 cases, with 
 work values above the average for the group, is 10.2, while the 
 average for the 11 cases below the group average (185) is 9, and 
 by comparing Chart 2 the average daily increase is 9.5 for the 
 normal group. Hence, in general we can state that in the normal 
 group the daily increase is proportionate to the total work per- 
 formed. 
 
 In the dementia praecox group we see more variation in the 
 relations of these values. The lowest daily increase 2.7 is found 
 in next the highest column, 230, and the highest daily increase, 
 12.4 in column 178, somewhat above the average 165. By com- 
 paring the daily increase in cases where the work values are above 
 the average, we find almost the same condition as in the normal. 
 The average of daily increase in five cases above the group aver- 
 age of work values is 8.5, which is 1.7 above the average daily 
 increase for the group, while 6.4 represents the average of the 
 seven columns below the group average. So that it can also be 
 said for dementia prsecox that the same conditions are demon- 
 strated as in the normal regarding the proportion of daily increase 
 to that amount of work done. 
 
 In the alcoholic group the variations in the daily increase show 
 much greater variations than either dementia praecox or normal, 
 between 19.2 and 2.^, and the average 9.5. Again considering the 
 cases which are above the group average, we find six cases with 
 an average of 11.6, and these below the group average in work 
 values, eight cases with an average of 7.4. Again the rule as 
 applied to the normal holds good for alcoholics, except that the 
 difference between these two averages is 4.2, which is greater 
 than either the normal or dementia praecox groups. 
 
 By comparing the three groups, as shown in Chart 2, we see 
 that the normal and alcoholic group are practically the same (9.5, 
 9.6), while dementia praecox falls far below, 6.8. And this is in 
 harmony with the facts shown in Chart i, in which the dementia 
 praecox group shows total capacity for work much below the 
 normal and alcoholic group.
 
 mental capacity in dementia precox i43 
 
 Effect of Practice (Ubung) 
 
 In close relation to the total intellectual capacity and average 
 daily increase, is the effect of practice, in fact, the total amount 
 of work accomplished and the average daily increase depend 
 largely upon the effect of practice. The effect of practice is 
 shown in average daily increase in the amount of work performed. 
 In Fig. 4 we have plotted typical curves for each of the three 
 groups. These curves are obtained by computing the amount of 
 work performed during the first five minutes each day, and mak- 
 ing a curve for these values for the ten consecutive days. Here, 
 again, this second five minutes can not be utilized because of the 
 pause as previously explained. 
 
 And for the same reason that we could not use actual figures 
 for constructing an average work for the various groups, we could 
 not construct a curve representing the effect of practice. There- 
 fore somewhat typical curves from each of the groups are selected. 
 In these curves the abscissa represents the days, and the ordinate 
 represents total amount of work done in the first five minutes 
 on each day. The normal curve shows a steady rise with slight 
 variations from 70 the first day to nearly 180 on the tenth day. 
 In other words, this individual did two and one half times the 
 amount of work on the tenth day as he did at the beginning, or 
 the increase was 250 per cent., due to practice and familiarity with 
 the work. Of course, all normal curves would not show this 
 tremendous increase, although they would approximate this curve 
 to some extent. 
 
 The curve representing a case from the dementia prgecox group, 
 we see a decided difference. It will be noticed at first that the 
 curve begins at a point where the normal ends, that is, the total 
 amount of work done is much greater than in the normal case. 
 This is shown on Chart i, where the column marked 230 is next 
 to the highest column of this group. But the average daily in- 
 crease is only 2.7, which is the lowest of the three groups. You 
 will notice that there is a very rapid rise for the first four days 
 (from 170 to 275 or 160 per cent, increase), then a sudden drop 
 to 210, and from here to the last variation, until the curve ends at 
 245, or 140 per cent, increase over the work done in the first 
 minute. This shows graphically the well known clinical symptom
 
 144 
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 U i 
 
 w «^ ^ 
 
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 MENTAL CAPACITY IN DEMENTIA PRECOX 1 45 
 
 of this form of mental disease, that is, a general emotional 
 apathy, a loss of interest in surroundings, work, pleasure, etc. 
 So then one is not surprised to find that this feature of the disease 
 is shown so well graphically by this method. And this curve is 
 not the most pronounced one of the group, but is fairly repre- 
 sentative of the group. The curve of the alcoholic patient is 
 nearly the same as the normal, and is also fairly representative 
 of this group, although some of the cases show more variation. 
 
 Susceptibility to Fatigue (Chart 3) 
 (Ermiidbarkeit) 
 
 We obtain the figures for the coefficient of fatigue, showing 
 susceptibility to fatigue by considering the general effect of the 
 pause upon the individual's work. This method was explained 
 in the first part of this paper, and will not be elucidated again. 
 
 By this method we obtain the values represented by the columns 
 in Chart 3. In the normal group we see variations in the coeffi- 
 cients from I to 17, and the average for the group is 6. It will 
 be seen that no negative values are present, as in the dementia 
 praecox and the alcoholic group. In the normal group, without 
 exception, the pause or rest has had a beneficial effect upon the 
 after work, as we saw in Fig. 3. This is not so, however, in the 
 dementia praecox group, for in the group 8 out of the 12 cases 
 show a negative coefficient of fatigue, varying from 5.1 to i, and 
 are represented by columns extending below the line o. The aver- 
 age for the group is only i. The average for the 8 negative cases 
 is — 2.8 This result is rather striking, and corresponds to the 
 facts explained in regard to curves shown in Fig. 3, only here 
 the comparison between the groups can be more distinctly made. 
 It can readily be seen that the effect of the rest was very unfavor- 
 able to the dementia prjecox group, and that fatigue was not 
 present in the large majority of cases. 
 
 In the alcoholic group the average 6.5 is just above the normal 
 and there is very little difference in the coefficients. However, 
 we have 3 negative cases out of 14, and these 3 cases were of the 
 dull stupid type so often seen among this group. In both groups 
 (dementia praecox and alcoholics) the cases in which the fatigue 
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 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 147 
 
 coefficient was negative, were also the cases with a smaller total 
 capacity in comparison with other cases of the same groups. 
 In Chart 4 the values representing the direct effect of the pause 
 
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 are shown. We have explained previously the method whereby 
 these values were obtained. Unfortunately, I was unable to obtain 
 in the normal group more than the values for 9 cases. But these
 
 148 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 show no negative values. The average for the normal group is 
 9.5, which is considerably below the average for the alcoholic 
 group, viz., 14. And this is also shown in Fig. 3 by the height of 
 the dotted line after the pause where it reaches 103. And this 
 has also been explained by the fact that in the alcoholic cases, 
 although the fatigue values are not much above normal, yet the 
 work after the pause shows an increase, probably because these 
 patients after the pause have lost the effect of the work given 
 before and start in as if they were beginning a new task. By 
 comparing the values of the impulse after the pause, as shown in 
 Chart 6, we find that in alcoholics the average for the group is 
 lighter than the average for the normal, 4.5 and 1.5, respectively. 
 And from these facts we can assume that the intensity of the 
 will is not lost as soon as in the case of the normal group, and 
 in consequence of this the alcoholics go to work after the pause 
 with greater intensity of the will, and the values of the work in 
 the sixth minute after the pause are higher than in the normal 
 group. Also the readiness for work is lost more quickly than in 
 the normal person, as explained above. 
 
 In dementia prsecox, however, during the pause, a different 
 process has been in operation. We have seen that no great 
 amount of fatigue is to be compensated or dissipated by the rest, 
 and the sudden decrease in the intensity of the will counterbalances 
 whatever recuperation from fatigue might have taken place. 
 Thus, the work of the last minute before the pause, and the next 
 minute following the pause (sixth minute) does not show such a 
 great difference as is the case in the alcoholic and the normal 
 groups. And here again we must take into account the absence 
 of a readiness for work, the presence of which is shown in alco- 
 holics and in normals. For through a certain indifference to the 
 work before them they show no anxiety to go ahead and do their 
 best. Hence in Chart 4, five cases out of 12 are represented by 
 negative values, and the average for the group is only 5 com- 
 pared with 9.5 and 14 for the normal and alcoholic group 
 respectively. 
 
 From these charts we can conclude, then, that the effect of the 
 pause or rest in the alcoholic and normal groups exerted a favor- 
 able influence upon the later work, especially in the former group. 
 But in the dementia praecox group a pause of the same length had
 
 MENTAL CAPACITY IN DEMENTIA PRECOX 1 49 
 
 a very unfavorable effect upon their work. That fatigue is greater 
 in alcoholics than in normal individuals has been shown by other 
 methods and experiments, and the facts found here corroborate 
 the views of other investigators. 
 
 Intensity of the Will (Impulse) 
 Chart 5 
 
 In normal individuals the intensity of the will, or the impulse 
 of the will is influenced by four factors, as follows: (i) In the 
 beginning of any work the feeling is that there is something to 
 be overcome, or some task to be performed, and that causes a 
 high tension of the will; (2) the intensity of the will is shown 
 at the end of a task when one wants to do as much as possible 
 before one finishes; (3) the entrance of fatigue causes a feeling 
 of weariness, and in order to overcome this feeling one, so to 
 speak, strains the will to greater activity; (4) after a disturbance 
 in a certain period of work or task, one's attention having been 
 distracted, one begins again to work, and the impulse of the will 
 is again shown. This is shown in the experiments by the decrease 
 in amount of work done in the second or third minute. Compar- 
 ing this with the first minute before and after the pause, we must 
 now endeavor to find how the normal relation is disturbed in our 
 abnormal groups. 
 
 We see that the initial impulse at the start of the task is much 
 greater in normal than in alcoholics or dementia praecox, thus, the 
 values are 29, 9 and 11, respectively. And when we consider that 
 the fatigue in the dementia praecox group is very small, the fact 
 that no great intensity of the will is present, these two facts har- 
 monize. By observing the combined work curve. Fig. 3, we will 
 see this explained. And if we have no marked impulse or tension 
 of the will the only way to explain this sudden decrease in the 
 third or fourth minute is by a sudden failure of the tension of the 
 will. The sudden sinking of the curve to 83 in dementia prascox 
 is in great contrast to the gradual sinking of the curve in alco- 
 holics and normal, respectively 89 and 91. These latter figures 
 show distinctly the effect of fatigue which has overcome the ten- 
 sion of the will. And we have seen that the fatigue is very small 
 in dementia prascox and cannot come into play in explanation of 
 the sudden sinking of the curve.
 
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 MENTAL CAPACITY IN DEMENTIA PR^ECOX I5I 
 
 The impulse after the pause shows two facts : First, that during 
 the pause the fatigue has been compensated in the alcoholics, and 
 in consequence we see a tremendous rise in the curve after the 
 pause. The curve rises to 103, which is higher than in the 
 start of the task, and the tension of the will is not as high as at 
 the start. How is it in dementia praecox? We have seen that 
 we have a lesser intensity of the will, and therefore less fatigue, 
 also a sudden sinking of the curve in the fourth minute. And we 
 have an apparent high point of the curve after the pause, but only 
 to 95.6, which is very much below the alcoholics. And during the 
 pause no recovery has taken place, and the work after the pause 
 is less than the alcoholics. Then follows again the sudden failure 
 of the tension of the will. The pause has been unfavorable, for 
 the amount of work done after the pause falls below the amount 
 of work done without a pause (see curve. Fig. 3). Again we 
 must take into account the readiness for work. 
 
 We must conclude that in both groups a rapid disappearance of 
 the readiness for work has taken place during the five minute 
 pause, and in normal this is explained by the fact that at the start 
 of the work the normal person shows a great deal of interest, but 
 after a short pause of five minutes the tension of the will has 
 decreased considerably compared with the tension before the 
 pause. We know from experience (although such a fact has not 
 been established experimentally) that normal persons hold the 
 readiness and interest for work during a short pause. And when 
 they again begin to work they have the feeling that the task is 
 not so difficult because they know what they have to do. There- 
 fore, they do not exert themselves, and the amount of work done 
 by the normal after the pause is much less than that performed 
 by the alcoholics. Also, at the end the curve sinks, while the 
 curve without pause rises a little bit because of practice and 
 familiarity. And we conclude (i) that the tension of the will 
 before and after the pause, which in dementia praecox and alco- 
 holics has very nearly the same value, is caused by the fact that 
 the readiness for work is rapidly lost during the pause, and they 
 begin to work after the pause just as if they had a new piece of 
 work to do. While the great difference of the normal will tension 
 before and after the pause is due to the fact that this readiness
 
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 MENTAL CAPACITY IN DEMENTIA PRECOX 1 53 
 
 for work has not disappeared, they are prepared for the task at 
 hand. 
 
 It can be demonstrated by experiment that after pauses or rest 
 periods of different lengths that the readiness for preparedness for 
 work in normal also is lost, and the tension of the will is grad- 
 ually increased when the time of the pause is lengthened. 
 
 Second. That the increase in the work done after the pause in 
 alcoholics is due to the dissipation* of fatigue during the pause, and 
 also the higher tension of the will. In dementia prsecox the total 
 capacity is not so high as in alcoholics, but the impulse of the will 
 is about the same as before and after the pause, because no fatigue 
 has been counterbalanced, and the readiness for work has disap- 
 peared. The irregular course of the work curve, now high, now 
 low, shows distinctly the fluctuation of the tension of the will. 
 
 In Chart 6 we have illustrated the impulse of the will after the 
 pause. What we have said regarding the work curves in Fig. 3 
 is corroborated by the facts deduced from this chart. In the 
 normal group we have 3 cases out of 29 showing negative values, 
 and the average for the group is only 1.5. In the dementia prsecox 
 group there are only 2 negative values out of 12 patients exam- 
 ined, and in the alcoholic group only 2 negative values out of 14 
 patients examined. The average for the dementia praecox group 
 is here shown to be higher than the other 2 groups, or 6.5 com- 
 pared to 1.5 normal and 4.5 alcoholic. And this greater value for 
 dementia praecox as compared with the normal and alcoholics is 
 only apparent, or when we consider the space between the sixth 
 minute dotted line and sixth minute full line in the 3 groups. In 
 Fig. 3 this increase is explained. It is not that the cases of 
 dementia praecox do so much more work after the pause, or that 
 the impulse is greater, but the sinking of the curve before the 
 pause due to the neglect of the will to act, accounts for this light 
 average in dementia praecox. 
 
 Conclusions 
 
 By the simple experimental procedure outlined in this paper, 
 we have shown : 
 
 I. That the disturbance of the will is the most important 
 symptom of Dementia Praecox. 
 
 ' Erhohlung.
 
 154 MENTAL CAPACITY IN DEMENTIA PRECOX 
 
 2. Because of this defect of the will, the rest from work, so 
 beneficial to normal individuals, and the alcoholic cases, has an 
 unfavorable influence in Dementia Praecox. 
 
 3. The effect of practice in Dementia Praecox is of much less 
 value than in normal persons and alcoholic cases, which conforms 
 to the general apathy shown in Dementia Praecox cases. 
 
 4. Absolute deflection of the will, a prominent symptom in 
 Dementia Praecox, is shown by this method. 
 
 5. Fatigue is absent in Dementia Praecox, and greater in 
 alcoholics than in normal persons. 
 
 6. Absolute mental capacity, as shown by the amount of work 
 performed, varies but little in the three groups, being less in 
 Dementia Praecox than in the other two. 
 
 7. That the daily average increase in the individual cases is 
 proportionate to the total amount of work performed, is true of 
 the three groups. 
 
 8. That the experimental results agree with the clinical symp- 
 toms of Dementia Praecox and Alcoholic Insanity.
 
 THE RELATIONSHIP OF HYSTERIA, PSYCHAS- 
 THENIA, AND DEMENTIA PRECOX 
 
 By Adolf Meyer, M.D. 
 
 PROFESSOR OF PSYCHIATRY, JOHNS HOPKINS UNIVERSITY 
 
 A report of two cases furnishes the material for our discus- 
 sion ; one of undoubted hysteria in which a catatonic dementia 
 praecox supervened ; and a case of psychasthenia with obvious 
 deterioration. Unfortunately the material for a discussion of the 
 present status of the conceptions of hysteria, psychasthenia, etc., 
 would prove too long even if I should limit myself to giving the 
 main facts, in view of the tremendous confusion that exists owing 
 to the ease with which programmes and definitions are launched, 
 and owing to the fact that as a rule the contentions are made 
 without documentation by actual records. To my regret I also 
 must abstain from the publication of my two cases in full, in the 
 form in which alone they would be wholly convincing. 
 
 Suffice it to say that the first case presented an hysterical hip 
 for one year at 1 1 ; a classical hysterical paraplegia with con- 
 vulsions for one year at 21, another four months of hysterical con- 
 vulsions and spinal and ovarian hyperesthesia at 23 ; finally at 28, 
 a psychosis of the character of hysterical delirium, with a relapse 
 which passed into a simple stupor; after one year the patient was 
 submitted to an aggressive thyroid treatment, passed into an 
 exhausting excitement, and after a few months into a classical 
 catatonic stupor lasting several years and relaxed but gradually. 
 Each of the above steps set in on the ground of decided strains ; 
 the development was fairly consistent and the residual after about 
 fifteen years since the first outspoken psychosis, a condition of 
 nursing a " pain " or a " disease " in the spine, stereotyped man- 
 ners, soliloquies in imaginary settings, but in the main a slow 
 response to efforts to reestablish a certain adaptability to her home 
 environment and to simple home interests. 
 
 The second case is that of a young man of 27, as a boy an 
 indiscriminate reader and imaginative, slightly odd at college, with 
 a growing obsession of incompleteness of his toilet, the brush- 
 
 155
 
 156 HYSTERIA, PSYCHASTHENIA AND DEMENTIA PRECOX 
 
 ing of the teeth and the drying after the bath — a feehng of damp- 
 ness, a desire to rub himself dry — incompleteness and indecision 
 are the patient's own words for his condition. The ruminative 
 episodes have become more and more automatic and they domi- 
 nate the patient's life with undeniable dilapidation of all capacity 
 of application and interest. 
 
 In teaching we can present the first case as one showing that 
 plain hysteria does not protect against dementia prsecox, or is not 
 incompatible with it, and more, namely, that the mechanism can 
 become progressive. 
 
 The second case shows that the simple deterioration may carry 
 with it the picture of psychasthenia, feeling of incompleteness and 
 indecision and automatism, and practically no other trait, under 
 which conditions we must nevertheless treat the disorder like one 
 of psychasthenia. 
 
 The relative inaccessibility of both cases makes it difficult to 
 reconstruct the whole picture of evolution as well as was done 
 in Dr. Hoch's cases. But they are suggestive at least as a foun- 
 dation to the question of the relation of hysteria, psychasthenia 
 and dementia prsecox. 
 
 For any discussion of such a relation we should review what 
 we would accept as safe ground concerning the entitiesv From 
 the point of view of teaching it would be desirable to keep the 
 three entities clearly apart if that agrees with the facts. From 
 the point of view of constructive work and analysis, it is better 
 to make the most, not necessarily of the identification with some 
 dogmatic compound picture which is sure to be open to unwar- 
 ranted twists by extraneous factors, but rather of the working 
 factors or determining conditions that constitute the deviation 
 in specific cases, and the modifiability of the conditions. This 
 constructive method is available in terms of reaction-types rather 
 than of disease entities.^ 
 
 The issue is a demand for safety and clearness in using the facts 
 at hand, a demand to work with what the case actually presents 
 rather than through identification with a compound picture which 
 we do not see and have to take on authority, with inevitable va- 
 rieties of definitions (I merely refer to Dr. Dana's recent effort 
 
 ^ Compare the Problems of Mental Reaction-Types, Mental Causes and 
 Diseases, Psycholog. Bulletin, Vol. V, 245-261.
 
 HYSTERIA, PSYCHASTHENIA AND DEMENTIA PRECOX 1 57 
 
 to limit hysteria and to create other types). The synthetic method 
 is also more apt to disclose factors worth knowing for prophy- 
 laxis, and can be taught as readily and efficiently for work as the 
 other, although perhaps not as easily for examinations. 
 
 The issue then is what reaction is at work? What are the de- 
 termining conditions? What is their modifiability? What are 
 the alternatives of prospect and their determination? 
 
 In this respect the Freud-Jung conceptions command most at- 
 tention, but they are to-day largely emphasis of a portion of the 
 situation. My personal preference is for a broad formulation of 
 the problems in terms of substitutive activity. 
 
 All biological function is an adaptation which demands for its 
 safe expression a statement of (i) the determining conditions, 
 (2) the form of the reaction, and (3) the result or terminal con- 
 dition. 
 
 Among the adaptative disorders which occupy us we do well to 
 try and make a fairly clean-cut distinction between simple insuf- 
 ficiency such as we see in imbecility and those disorders which 
 tend to be progressive and cumulative. Simple insufficiency may 
 make impossible certain reactions, but need not expose the indi- 
 vidual to destructive false attempts. The borderland between 
 imbecility and positive substitutive reactions begins where the in- 
 dividual does not merely fail to react but uses poorly planned and 
 ill-adapted make-shifts, such as tend to undermine the develop- 
 rjient or maintenance of healthy instincts. 
 
 We deal in the first place with a great number of individuals 
 with non-systematized constitutional inferiority, forming the bor- 
 derland between imbecility and the essentially pathological sub- 
 stitutive reaction types. 
 
 The next level of reaction is the neurasthenic which according 
 to Dejerine and Moebius may be looked upon as the common 
 source of the other neuroses, or if you wish to put it the other 
 way, the prodromal type of many further developments. The 
 hypochondriacal reaction type would be closely connected with it ; 
 the psychasthenic with its ruminations and obsessions and auto- 
 matisms and panics would form another branch. The hysterical 
 reaction type with its submersion and conversion into most dis- 
 tinct examples of substitutive reactions, forms the group which 
 more than any other occupies the physician because it shows
 
 158 HYSTERIA, PSYCH ASTHENIA AND DEMENTIA PRECOX 
 
 US clearly the involvement of the physical component of our 
 mental activity. 
 
 Psychology is but reluctantly coming to size up its data in terms 
 of conduct and behavior, with due attention to the actual physical 
 component. We find further the merely dilapidating or dis- 
 tinctly incongruous reaction types marking the tendency to dete- 
 rioration ; the scattered fantastic ruminations or the tense cata- 
 tonic types, or the sham consistency of the paranoic development. 
 Quite a few paranoic conditions belong to this group, whereas the 
 manic-depressive reaction type would in many instances remain 
 more or less doubtful in its position and seem to be more akin to 
 the not clearly psychologically determined epilepsy series of physi- 
 ological fluctuations. As all biological terms, such a conception as 
 substitutive activity has its specially appropriate centers of utility 
 and it shades off into domains where it is less useful. It is plain 
 enough in the psychasthenic and hysterical symptoms which are 
 plainly substitutions for what is dodged. 
 
 One common method is to speak of distinct " diseases," and I, 
 without mentioning the term " disease " especially, would indeed 
 speak of " pure cultures of reaction types," of cases in which a 
 special reaction type is dominant, and of cases in which it is in- 
 cidental or subordinate. The terms which stand for the formula 
 of specific diseases are of didactic importance and especially jus- 
 tified, because some of the reactions practically exclude one 
 another as is the case between hysteria and psychasthenia, 
 whereas, other combinations are compatible and produce all those 
 transition forms which resist definition as units. In any case a 
 definition should contain the essence of the mechanism. Dr. 
 Dana speaks of the disease hysteria as being a morbid mental 
 condition in which ideas or emotional stress seriously and un- 
 wittingly control the body and produce more or less permanent 
 and objective morbid states, — and he then uses as the protype 
 those cases produced by railroad accidents, shocks and collisions 
 and alcoholism ; i. e., cases in which the non-psychic nervous dis- 
 orders are evidently very predominant and with them the fre- 
 quently bad prognosis : whereas most of the other hysterias are 
 classed with the psychataxias or psychasthenias as not true 
 hysteria. It ought to be plain that unless we make identification 
 with a name the main issue, it is better to train the student to think
 
 HYSTERIA, PSYCHASTHENIA AND DEMENTIA PRECOX I 59 
 
 of pure and impure or complicated reaction types rather than of 
 " true " hysteria, psychasthenia, etc., making a disease of an arbi- 
 trarily limited group of cases, without evidence that the funda- 
 mental definition explains these cases and with serious reasons 
 to assume that really, matters not mentioned in the definition give 
 the group its character. It is especially undesirable to accept a 
 set of nosological units put forth without the documental ma- 
 terial of records to back up the contentions as is the case with 
 Kraepelin. 
 
 With these principles in mind I reserve the term dementia 
 praecox to the essential deteriorations in which there is absolutely 
 no doubt about the deterioration, and give some descriptive term 
 to the reaction type at hand, hysterical, psychasthenic, hebephrenic, 
 catatonic, paranoid, or whatever designates the mechanism as long 
 as deterioration is not in the center. I do this with all the more 
 justification if I consider that Kraepelin in his book says that 
 among the admissions to a clinic the dementia prsecox cases form 
 but a slightly higher percentage than the manic depressive ; whereas 
 Wilmanns on the same material from Heidelberg reports that 
 between 1901 and 1905 the rate of dementia praecox varied be- 
 tween 40 and 52 per cent, of admissions, and the manic-depressive 
 ranked between 11 and 16 per cent. The question thus arises very 
 seriously — is it right to swell the issue of the probable or possi- 
 ble outcome to such importance as to become the, leading con- 
 ception of the disease? This idea is in the ascendency just now. 
 Two years ago Janet told me that annually a number of hysterical 
 patients were transferred to the insane wards with deterioration ; 
 last summer he felt inclined to yield to the tendency to mark these 
 cases outright as cases of dementia prascox. In his descriptions 
 of psychasthenia, however, he shows a number of cases of prog- 
 ress to deterioration similar to my second case. Peterson 
 and Jung refer to the fact that there are many cases of de- 
 mentia praecox which for years are not to be distinguished from 
 hysteria and that a large number of catatonic processes were for- 
 merly called degenerative hysterical psychoses. Jung's analysis 
 shows very clearly the common factor in the developments of a 
 hysterical and of a deterioration reaction. If he speaks of the 
 stabilization of the complex he gives a plain expression of the 
 plain fact ; but he yields to the temptation of accounting for this
 
 l6o HYSTERIA, PSYCHASTHENIA AND DEMENTIA PRJECOX 
 
 stabilization, etc., by toxines, a method which to my mind leaves 
 too readily the functional ground on which the whole investiga- 
 tion has prospered and the plain facts are exposed. 
 
 I thus come to the next point of the discussion ; that is, what 
 constitutes the unfavorable reaction type? As I pointed out 
 in a paper read before this society over three years ago, and 
 again in the Toronto discussion^ we have strong reasons to con- 
 sider the foundation for these reaction types to be the result of 
 conflicts and deviations of instincts, and in cases of deteriora- 
 tions we find invariably that the complex-phenomena occur in an 
 especially vulnerable field, or denote from the start the deficiency 
 of balancing instincts. 
 
 Why should a patient drift so strongly into more or less 
 absurd imaginations pre-eminently in the sexual domain, in re- 
 ligious elaborations and in fantastic spheres? Why should there 
 be such a striking tendency to ideas of reference which denote so 
 strongly a feeling of inferiority of action? What determines the 
 striking tendency to feelings of passivity, of being influenced, 
 etc., in the automatisms, which the more hysterical takes in a 
 self-possessed, not in a passive attitude? A careful study of 
 the cases shows the ravages of habitually incomplete or directly 
 inadequate and ill-adapted and ill-controlled reactions, a tendency 
 away from the contact with reality and self-correction, a scatter- 
 ing of the personality, with or without the sham consistency 
 which we see in the paranoic forms, and through it all a stultify- 
 ing of the instincts which are essential for balancing in the com- 
 plex demands of life. We, therefore, attribute a pernicious effect 
 to a trauma in the sense of Freud and Jung, even when, instead of 
 its merely leading to the hysterical reaction type, it plays a role 
 in an actual interference of development of instincts. In this 
 respect it takes little skill to realize how different the sexual evolu- 
 tion of the hysterical is from that of the dementia praecox case; 
 there is much more inferiority or miscarriage of function in the 
 future dementia precox case, to suggest voices or electric cur- 
 rents in the womb, or the imaginations of love answered by a 
 stranger through passive movements of the tongue. In all this 
 we invariably see additional interweaving of habit-deteriorations, 
 ruminations instead of youthful pranks and of a rash trial and 
 
 * British Medical Journal, September, 1906.
 
 HYSTERIA, PSYCHASTHENIA AND DEMENTIA PRJECOX l6l 
 
 rejection method of the more wholesome development, with its 
 instinct for touch with reality. And beside these defects we see 
 precocious one-sided moralizing, top-heaviness, leading the patient 
 further and further away from the life with concrete correc- 
 tions. 
 
 The effect of the spreading into ill-protected domains and the 
 determination of the seriousness of such combinations is easy to 
 demonstrate in the question of masturbation, which to this day is 
 dealt with in the most dogmatic and absurd fashion by a large 
 number of physicians who think they can settle the issue by the 
 negation of all importance, and the mere assumption of funda- 
 mental defect where it happens to lead to disaster. Masturbation, 
 like the use of alcohol, must be judged specially in every case. 
 
 It will be the task of a publication of a sufficient number of 
 thoroughly studied cases to show the lines of cleavage between 
 deviations of instincts which do and others which do not tend to 
 become progressively destructive. To think of these matters in 
 terms of auto-intoxication is not ruled out if such a relation is 
 demonstrated, nor should we of course be satisfied with an 
 abstract statement that we deal with conflicts and deterioration of 
 instincts ; but at the present juncture it is best to recognize the 
 probability that in many cases a number of factors combine and 
 that among these many can only be expressed in activities, habits 
 and instincts and that a sweeping over-simplifying terminology 
 obscures the clearness of observation and reasoning. 
 
 Neurology has led us too much out of a functional appreciation 
 of developments. It reasons largely with stationary and progres- 
 sive focal conditions and their occasional repair, rather than with 
 balancing mechanisms, such as we must work with in psycho- 
 pathology. 
 
 The conception of substitutive reactions brings us back to a 
 normal foundation of direct activity again. It frees us from ex- 
 cessive definitions at the loose end, furthers definition of the 
 actual situation and of the means of adaptation available in the 
 patient. Instead of a plan of identification with names of arbi- 
 trary patterns we get attention to the facts at hand without arbi- 
 trary expurgations. We can see and teach what we have in the 
 pure cultures of hysteria, psychasthenia, and dementia prascox, 
 and if we find collaboration of special factors, we have a place 
 
 12
 
 1 62 HYSTERIA, PSYCHASTHENIA AND DEMENTIA PRECOX 
 
 for them according to the facts, be they of the type of regulation 
 of conduct and behavior, i. e., mental, or infrapsychical, toxic 
 or what not. 
 
 This mode of presentation can be made just as simple as that 
 which works with disease-entities and much more just and espe- 
 ially much more valuable in plans of handling the case and in 
 shaping facts for prophylaxis.
 
 AN EXPERIMENTAL STUDY OF THE OCULAR 
 
 REACTIONS IN THE PSYCHOSES, FROM 
 
 PHOTOGRAPHIC RECORDS 
 
 By Allen Ross Diefendorf, M.D. 
 
 LECTURER IN PSYCHIATRY IN YALE UNIVERSITY MEDICAL SCHOOL 
 
 AND Raymond Dodge, Ph.D. 
 
 PROFESSOR OF PSYCHOLOGY IN WESLEYAN UNIVERSITY 
 
 Within the last few years exact knowledge of the normal move- 
 ments of the eyes has made rapid advance, particularly in Amer- 
 ica, through the use of mechanical and photographic registering 
 devices. Quantitative information is now at hand with respect 
 to the angle-velocity (2, 3, 9)^ and the path of the line of regard 
 during rapid eye-movements (4-6, 8, 10-16),^ the accuracy, sta- 
 bility and variability of fixation under a considerable variety of 
 circumstances (4, 6, 8, iQ-15),^ the ocular reaction-time (8),* 
 and the peculiar modifications of eye-movements which consti- 
 tute short-lived motor habits (5),^ pursuit movements (7),^ co- 
 ordinate compensatory eye-movements (7, 8),^ and the move- 
 ments of convergence (12).^ 
 
 The ease with which the photographic technique can be adapted 
 to a wide variety of experimental requirements, together with 
 certain peculiarities of the eye-movements themselves, led the 
 writers to believe that a comparative study of the eye-movements 
 of normal and insane persons might be made a fruitful contri- 
 bution to our experimental knowledge of the reactions of the 
 insane. 
 
 Such a comparative study might well find its basis in any of a 
 large variety of experimental data. The present investigation was 
 limited to three main problems, which were relatively clear to us, 
 and to meet which we framed our technique. 
 
 The difficulties in any experimental study of normal psycho- 
 
 ^ Numbers i to 16 refer to the bibliography at the end of the paper. 
 
 163
 
 164 OCULAR REACTIONS IN THE PSYCHOSES 
 
 physical processes are serious enough, even though one may rely 
 on the highest degree of intelligent cooperation on the part of the 
 subject. In the study of abnormal mental life, additional diffi- 
 culties arise from the very nature of the object of investigation, 
 in direct proportion to its variation from the normal. As 
 Kraepelin cogently observes, lack of comprehension of the ex- 
 perimental test, lack of ability to execute it, lack of interest, 
 cooperation, and of endurance, all conspire to increase the task 
 of the experimenter and to modify the value of his results. The 
 consequent demand for trustworthy experimental methods, which, 
 without too complicated technique or too unusual demands on the 
 patient, shall yield quantitative information of significant varia- 
 tions from normal reactions, voices at once the need and the 
 embarrassment of experimental psychiatry. These demands are 
 met in part at least by the reactions of the eyes as they are known 
 through their photographic records. 
 
 Eye-movements are neither unusual nor difficult. On the con- 
 trary, the ability to look at a bright object which appears suddenly 
 within the field of view is one of the earliest forms of motor 
 organization to be achieved, and it is retained long after the 
 ability to learn new and complex forms of reaction is irretrievably 
 lost. A patient will naturally look at a suddenly appearing object 
 when he could learn the simplest new reaction only imperfectly 
 and with enormous waste of time. 
 
 Moreover, while the eye-movements are intimately associated 
 with the most complex mental activities, they are peculiarly inac- 
 cessible to subjective observation. Even the best trained observers 
 utterly failed by introspection to discover some of the facts of 
 eye-movements which are most conspicuous in the photographic 
 records. For the ordinary man, his eye-movements are usually 
 involuntary and unconscious ; they are essentially a part of the 
 mechanical preadjustments of vision, and consciousness is con- 
 cerned with the result rather than the preadjustments. They may 
 on occasion be consciously initiated, but once begun they are 
 entirely withdrawn from conscious control. This effectually pre- 
 vents both arbitrary modifications and successful simulation of 
 pathological symptoms. Moreover, relative uniformity in the 
 previous training gives unequalled opportunity for legitimate 
 comparison between different persons. Probably no other form
 
 OCULAR REACTIONS IN THE PSYCHOSES 1 65 
 
 of reaction is common to so many different persons in so high a 
 state of development. The nearest competitors in this respect are 
 the various speech functions ; but gross differences of individual 
 habits and training render generalization concerning the latter 
 more difficult. In the eye-movements, on the other hand, we may 
 reasonably assume almost complete identity of practice and a 
 general high grade of efficiency. 
 
 Finally, the technique of recording the eye-movements is rela- 
 tively simple. By using the corneal reflection as the registering 
 medium, there is absolutely no discomfort to the patient and no 
 unusual stimulus to excite him, while the real purport of the 
 experiment may be entirely hidden under the instructions to the 
 patient to read exposed figures, letters, or short words, or simply 
 to try if he can see anything at all on the black screen. 
 
 On the other hand, the photographic procedure is not without 
 some difficulties of its own. The eyelid may droop and interfere 
 with the recording light without parallel interference with vision. 
 Excessive head-movements may render a considerable portion of 
 the plate illegible or take the patient out of focus of the record- 
 ing camera. But the records themselves are their own vindica- 
 tion, and we venture to believe that those who can appreciate the 
 experimental difficulties of securing trustworthy comparative data 
 will find some satisfaction in our results, and reasonable ground 
 for expecting more of the general procedure in the future. 
 
 The most serious limitations of our technique arise from de- 
 fective vision. Just how far this may finally be found an embar- 
 rassment it is difficult to predict, since the technique permits some 
 use of correcting glasses. The series of experiments we under- 
 took was planned to render a considerable range of visual defects 
 indifferent ; nevertheless, in three cases we were compelled to 
 abandon the tests because of gross refractive errors. 
 
 For both of us the most surprising feature of the experiment 
 was the conduct of the patients during the tests. We anticipated 
 a considerable variety of troubles, particularly from the maniacal 
 patients, and safeguarded the apparatus in a number of entirely 
 unnecessary ways. Naturally the worst cases of maniacal excite- 
 ment were not requisitioned ; but, as will later appear in detail, 
 we succeeded in getting excellent records from patients that in 
 the wards appeared utterly impossible.
 
 1 66 OCULAR REACTIONS IN THE PSYCHOSES 
 
 In only two cases did we encounter any unwillingness to par- 
 ticipate in the tests. Something about the experiments seemed to 
 appeal to the patients. The majority were helpful in getting into 
 position and maintaining it. Many seemed thoroughly to enjoy 
 the sessions ; some were interested in the results ; some were more 
 sensitive than others to the blue light, as was evidenced by an 
 occasional increased tendency to wink or to withdraw entirely 
 from the apparatus, but the light was stopped down by blue glass 
 so that continuous fixation produced only a mild and inoffensive 
 after-image. Many of the patients apparently failed to notice it. 
 
 Apparatus and Technique 
 
 The registering device for recording the eye-reactions was a 
 modification of the Dodge photochronograph which was designed 
 by one of the authors, and has been used by him practically in its 
 present form during the last five years. 
 
 As used by us it consisted of an enlarging camera of fixed 
 length (about 5 ft. [153 cm.]) fitted with a Bausch and Lomb 
 convertible protar. Series VIIa. The device for producing a reg- 
 ular motion of the sensitive photographic plate was the Dodge- 
 Cline falling plate-holder. It consists of a light-tight box 2 ft. 
 (61 cm.) high and 7 in. (17.8 cm.) wide, fitted with opaque slides, 
 and capable of quick adjustment to the rear of the enlarging 
 camera like a regular plate-holder. Within the box a movable 
 frame, holding a 5 in. (12.7 cm.) by 7 in. (17.8 cm.) photographic 
 plate, slides vertically on two brass tracks, so adjusted that all 
 lateral play is taken up by springs. The movement of the sliding 
 plate frame is accurately controlled by a simple hydrostatic device. 
 The frame is attached to a piston-rod ending in a plunger which 
 works in a vertical cylinder of lubricating oil. The valve of the 
 plunger offers no resistance as the latter is raised through the oil, 
 but it absolutely resists every effort to force it downwards. The 
 release of the plate is effected by opening a stop-cock below the 
 plunger, when the weight of the plate-holder forces the oil out 
 of the cylinder at the bottom through the stop-cock, and returns 
 it to the top of the cylinder above the plunger. The velocity of 
 the fall is determined by the opening of the stop-cock, the vis- 
 cosity of the oil, and the weight of the frame and plate.
 
 OCULAR REACTIONS IN THE PSYCHOSES 1 6/ 
 
 The photographic record is made on the falHng plate by photo- 
 graphing the image of an electric arc as it appears at the cornea 
 of the eye. The rays of the arc light are first passed through blue 
 glass screens to eliminate the photographically useless but physio- 
 logically disturbing rays of the lower spectrum. Those rays 
 which are then reflected from the convex surface of the cornea 
 to the camera are brought to a focus on the photographic plate 
 by the lens of the enlarging camera. 
 
 A convenient and well-nigh necessary modification of the plate- 
 holder was introduced for the first time in the present experi- 
 ments. Since one cannot presuppose much cooperation on the 
 part of the insane in finding and maintaining the proper position 
 of the head, it was found impossible to rely on methods of focus- 
 ing that were satisfactory for normal subjects. A focusing and 
 finding glass was consequently introduced into the falling plate- 
 holder just below the photographic plate, and in the same plane. 
 A system of automatic screens was arranged, so that during the 
 focusing process the plate was entirely protected from light. In 
 this way we could quietly await the opportune moment and quickly 
 adjust the apparatus to changes in the patient's position. The 
 apparent movement of the corneal reflection is slightly less than 
 half the actual movement of the eyes.- 
 
 But the actual displacement is magnified by the enlarging 
 camera so that the total record is a continuous curve whose ampli- 
 tude is about three times the actual amplitude of horizontal eye- 
 movements, and whose height is determined by the velocity of the 
 plate. Under the above circumstances, continuous visual fixation 
 will be recorded as a straight vertical line on the falling plate, 
 while any horizontal movement of the eyes will be indicated by 
 an oblique line whose obliquity depends on the relative velocity 
 of the horizontal and vertical components. 
 
 The difference in illumination between the corneal reflection of 
 the arc light and its background is sufficiently marked, so that 
 on a perfect plate there is no trace of other impressions except 
 the record made by the corneal image of the arc light. This 
 should appear as a fine black hair-line on an almost clear back- 
 
 ^ For the mathematical theory of the movements of the corneal reflec- 
 tion and empirical tests of its accuracy as a measure of eye-movements, 
 see Dodge, Experimental Study of Visual Fixation (8).
 
 l68 OCULAR REACTIONS IN THE PSYCHOSES 
 
 ground. No limit has been reached in the number of records one 
 plate will hold, except the purely mechanical confusion of the 
 lines. 
 
 In our experiments the stimulus was so arranged as to begin 
 coincidently with the beginning of the record. When the velocity 
 of the plate is known, the duration of an eye-reaction will be 
 given by the height of the vertical line of eye-fixation between 
 the beginning of the record and the beginning of the oblique line 
 of eye-movement. The velocity of horizontal eye-movement 
 should be given by the obliquity of the line of eye-movement, i. e., 
 the time, as measured by the fall of the plate, between one fixa- 
 tion and its successor. 
 
 Two series of records were made. One depended for its time- 
 record on the measured length and obliquity of the lines. In the 
 other an interruption of the recording light by a tuning-fork gave 
 the time directly in vibrations of the tuning-fork. Notwithstand- 
 ing a complex system of controls, our first records of the angle- 
 velocity of the eyes by the former method involved such serious 
 sources of error that we were reluctantly constrained to abandon 
 them as practically useless. They do not appear in this report. 
 The reaction-records, on the other hand, were about equally satis- 
 factory in both series. Each record involves a probable error of 
 less than o.oi second. 
 
 In convenience of control and in general trustworthiness the 
 tuning-fork interruption of the recording light is a decided ad- 
 vantage. It was arranged as follows : 
 
 An arc light, with horizontal upper carbon, was mounted on a 
 heavy optical bench behind a large condensing lens. In front of 
 this lens, and at the point where the latter brought the rays of the 
 arc light to a focus, was placed an opaque screen with an opening 
 which was so shaped and oriented that at each vibration of an 
 electric tuning-fork (a tested Koenig tuning-fork of 100.12 c.-p. 
 per second) the opening was alternately opened and closed to the 
 passage of the light from the arc. A second smaller lens of 6 in. 
 focus was so placed as to render the transmitted rays parallel. 
 From the position of the subject one isolated vibration of the fork 
 exposed the arc light and cut it off again. With this interrupted 
 light, when the tuning-fork was in continuous vibration, each 
 record of the corneal reflection appeared on the slowly falling
 
 OCULAR REACTIONS IN THE PSYCHOSES 1 69 
 
 photographic plate as a line of black points or dashes. From the 
 beginning of one dash to the beginning of the next represented 
 a time interval of o.oi second. The duration of any fixation or 
 of any eye-movement could be read directly from the appropriate 
 record in units of O.oi second by counting the corresponding dots. 
 The arclight and the tuning-fork interrupter were placed in one 
 corner of the laboratory at a distance of about 15 ft. (459 cm.) 
 from the patient. The patient was seated comfortably at the 
 apparatus just in front of the enlarging camera. His head was 
 held as firmly as practicable against a side-rest and a nosepiece.^ 
 Further constraint seemed inadvisable. The resulting records 
 were considerably complicated by head-movements, but our im- 
 mediate interest was not a study of the spatial characteristics of 
 the eye-movements, but rather a study of their temporal succes- 
 sion. For this purpose the records were unequivocal, except in 
 a few cases. No patient was in the apparatus more than thirty 
 minutes. Under favorable circumstances the tests occupied about 
 fifteen minutes, including periods of relaxation. All records are 
 for monocular vision. A black cardboard screen completely hid 
 the unused eye. Three groups of tests were made on each patient 
 at each sitting, and all three groups were recorded on the same 
 
 * Figure i, a half tone, could not be inserted here. It is a picture of 
 the entire apparatus set up and shows on the left the subject com- 
 fortably seated in a chair with the arms resting on the table and the head 
 placed against a side, top and nose rest. About one foot in front and on 
 a level with the eyes there is a single photographic lens fitted in the end 
 of an enlarging camera box five feet long with an appropriate standard 
 and terminating in the box of the falling plate holder, all resting on the 
 same long table. On the extreme right and fifteen feet distance from 
 the subject on another table is the light apparatus with appropriate hood, 
 lenses and colored glass screen to produce the desired rays, so thoroughly 
 stopped down as not to lighten the darkened room and in front of these 
 the black screen with the Koenig tuning fork, resting on the same table. 
 Partly hidden by the camera box, resting on the same table with it one 
 and one half feet in front and a little to the left of the patient is shown 
 two large black screens with openings for the arc recording light. These 
 screens are as nearly as possible in the same plane, the rear one being 
 movable and carrying the test objects for exposure through the openings 
 in the front one. Immediately in front of this is swung the pendulum, 
 which, when not in use, is hitched up out of sight of the subject.
 
 I/O OCULAR REACTIONS IN THE PSYCHOSES 
 
 plate. In this way each plate made a complete experimental 
 record of a single patient at the time of examination. The plates 
 were carefully numbered, and each number was entered in a 
 permanent record against the name of the subject, with such addi- 
 tional notes of the clinical picture and conduct of the patient as 
 seemed pertinent. 
 
 The experiment which we undertook included three tests for 
 distinct but inter-related phenomena. 
 
 I. Velocity of Eye-Movements 
 (A) Theory 
 
 The first test concerned the angle-velocity of simple reactive 
 eye-movement. Experiments on normal individuals have shown 
 a remarkable uniformity in the angle-velocity of similar uninter- 
 rupted eye-movements of the same person, quite independent of 
 direct conscious effort to move the eyes fast or slowly. There 
 are slight variations of the two eyes, and slight variations in suc- 
 cessive movements, but under similar circumstances these varia- 
 tions are relatively small. The first published records of the 
 angle-velocity of the eye-movements noted a slight but clear slow- 
 ing up of a rapid succession of eye-movements toward the end 
 of a series of ten movements. This was tentatively attributed to 
 fatigue. A series of records taken in connection with a hitherto 
 unpublished study of fatigue confirmed the previous findings and 
 justified the hypothesis that retardation of the velocity of the 
 eye-movements is a phenomenon of fatigue. 
 
 Valuable as they undoubtedly would be, it was hardly to be 
 expected that adequate fatigue tests could be obtained from the 
 insane. On the other hand, it seemed plausible that the different 
 disease processes, in so far as they affected the psychomotor 
 processes at all, would variously affect the angle-velocity of the 
 eye-movements. It also seemed probable that such variations in 
 a type of movement which is equally practised for all subjects and 
 is almost entirely removed from the effects of voluntary caprice, 
 would furnish exceptionally trustworthy comparative data. 
 
 Naturally, our immediate interest centered in patients suffering 
 from maniacal-depressive insanity, where, as a matter of fact, the
 
 OCULAR REACTIONS IN THE PSYCHOSES I71 
 
 most marked variations from normal velocity were found, but the 
 results of the test in other disease-processes are not without 
 interest. 
 
 (B) Experimental Conditions 
 
 The test for the angle-velocity of the eye-movements necessi- 
 tated the experimental production of a considerable number of 
 rapid reactive eye-movements of the first type (Dodge [7]) of 
 approximately the same amplitude. Taking advantage of the 
 fact that rapid eye-movements separate the fixation-pauses (or 
 moments of clear vision) in reading, we satisfied the experimental 
 requirement by exposing a succession of isolated numerals in two 
 dififerent parts of the field of regard about 25° apart. The read- 
 ing of one numeral by the patient was the signal for the operator 
 to cover it and to expose another 25° from the former. When 
 the latter was read, it in turn disappeared and another was ex- 
 posed where the first had been. 
 
 The eyes rarely moved through the entire 25° from numeral to 
 numeral in a single rapid eye-movement. This was entirely con- 
 gruent with the known facts that practically every long eye- 
 movement involves more or less final readjustment in the form 
 ■of short corrective movements. When the object of interest is 
 relatively obscure, like a numeral 25° from the fixation-point, 
 the normal end-corrective movements will vary from 1° to 5°. 
 In the great majority of cases the corrective movement is in the 
 same direction as the initial movement. This indicates that the 
 initial movement was too short. If the corrective movement was 
 negative, or if it exceeded one-sixth of the total displacement, the 
 record was discarded. The average main corrective movements 
 in our accepted records is about 3°. This reduces the average 
 displacement corresponding with our records to about 22°. 
 
 A large black screen was placed at i8 in. (45.75 cm.) in front 
 of the subject, at one side of the camera. This screen was per- 
 manent and served all three experiments. It was pierced by three 
 openings in the same horizontal line. Two openings for the 
 exposure of objects were 8 in. (20.4 cm.) apart. The middle 
 opening for the passage of the blue recording light was 5^ in. (14 
 cm.) from the left hand opening and was lost in the blind spot of
 
 1/2 OCULAR REACTIONS IN THE PSYCHOSES 
 
 the right eye when the center of the left hand opening was fixed. 
 This arrangement with respect to the bHnd spot was designed to 
 lessen distraction by the light during the preliminary focusing of 
 the camera. A movable black cardboard screen behind the per- 
 manent screen carried a series of numerals. These were so ori- 
 ented that as the screen fell, step by step, the numbers were suc- 
 cessively exposed at the appropriate openings of the fixed screen. 
 The movements of the screen were regulated by the operator. 
 The signal to the operator was the reading of the exposed 
 numerals by the subject. The amplitude of each movement of the 
 screen was automatically regulated by an appropriate escapement. 
 
 Before each series of experiments two numbers were exposed 
 respectively in the left and right hand opening, the middle one 
 being closed. The patient was told that other numbers would 
 appear in the same places, and that these were to be read aloud 
 as rapidly as possible. Foreigners were encouraged to use the 
 most familiar language. With the initial movement of the screen 
 the middle opening was uncovered, allowing the subdued arc light 
 to illuminate the subject's eye. Four groups of these movement- 
 records were taken for each subject, making, when all the lines 
 were legible, twenty-four movements. This number was unneces- 
 sarily large, since the mean variation is regularly less than half 
 of the unit of measurement, but a tendency to coordinate winking 
 just at the time of eye-movements together with head-movements 
 and interrupted eye-movements made some of the individual 
 records useless. 
 
 Since the illumination of the subject's eye was the condition of 
 a photographic record, the simultaneous exposure and illumination 
 were a mechanical guarantee that the beginning of the photo- 
 graphic record was synchronous with the appearance of the stimu- 
 lus to eye-movement. This arrangement gave the chief instru- 
 mental condition for the second and third series of experiments to 
 determine the reaction-time of the ocular movements. 
 
 (C) Results 
 
 Table I shows the average duration of eye-movements of cr. 
 22 for nine normals, twenty-one maniacal-depressives, in both the 
 maniacal and depressive phases, four cases of dementia praecox
 
 OCULAR REACTIONS IN THE PSYCHOSES 
 
 173 
 
 of the hebephrenic type, four epileptics, six paretics and one 
 imbecile. 
 
 Under each form of insanity the data are arranged according to 
 the severity of the disease. The most marked cases come first. 
 Each case is described at length under the corresponding number 
 in the Appendix. All time-values are given in M.000 second. 
 
 I 
 2 
 3 
 4 
 
 9 
 10 
 
 Normal 
 
 . R. D. . 
 
 . A 
 
 . Wh. ., 
 
 . Wr. .. 
 
 Female Nurses 
 
 LI 
 
 E. F 
 
 Male Nurses 
 
 11 W. S. ... 
 
 12 J. R. ... 
 
 59 
 59 
 61 
 60 
 
 60 
 54 
 
 62 
 60 
 
 13 
 14 
 15 
 18 
 
 19 
 Average 
 
 TABLE I 
 
 Mania' 
 
 Marked 
 
 . S. S 
 
 . J. c 
 
 . W. B. .. 
 . T S. ... 
 . J. G. ... 
 
 Depression' 
 Marked 
 
 59 26 .... H. N. (a-c) 55 
 
 44 32 .... P. F. (a) .. 74 
 
 60 29 R. R yy 
 
 51 Average 69 
 
 55 
 
 54 Less Marked 
 
 33 K; B 72 
 
 Less Marked 
 
 31 ... L. K. (b) . 
 
 21 ... A. H 
 
 27 ... M. G. (c-d) 
 
 33 ... KB. (b) . 
 
 60 
 
 56 34 •• 
 
 47 High 
 
 59 Low 
 
 Recovered Patient Average 55 
 
 17 M. D. (c) 
 
 Average 
 
 Low 
 
 High 
 
 M. V 
 
 60 
 59 
 54 
 62 
 
 1-5 
 
 Hypomania 
 
 22 ... G 50 
 
 29 ... R. R. (a) . . 65 
 
 23 ... A. T 76 
 
 20 . . . S. K. (c) . . 51 
 
 24 ... P. B 61 
 
 25 ... P. R 70 
 
 Average 62 
 
 Low 44, marked 
 
 High 76, hypo 
 
 Slight 
 
 T B SI 
 
 . . . 77 — marked 
 ... 51— slight 
 
 Dementia Precox Dementia Paralytica 
 
 36 
 37 
 
 Marked 
 . A. R. . 
 . M. B. . 
 
 Moderate 
 
 40 G. L. . . 
 
 41 M.F. . 
 
 62 
 
 52 
 
 60 
 
 50 
 
 Marked 
 
 43 D.D. 
 
 44 W. H. 
 
 45 A. B. 
 
 47 A. S. . 
 
 Average 
 
 54 
 53 
 60 
 60 
 
 57 
 
 51 
 52 
 
 Epileptic 
 
 Moderate 
 .. G. L. .. 
 . . J. F. . . 
 
 53 H.O. 
 
 54 •• 
 
 M. B. 
 
 Average 
 
 ' Maniacal phase of manic-depressive insanity. 
 * Depressed phase of manic-depressive insanity. 
 
 67 
 64 
 67 
 80 
 69
 
 1/4 OCULAR REACTIONS IN THE PSYCHOSES 
 
 Less Marked 
 
 Slight 48 J. P. E. .. . 54 Imbecile 
 
 42 B. M 56 49 J. A 49 57 R. H 60 
 
 Average 56 Average 51 
 
 From the preceding table (I) it is obvious that the velocity of 
 the eye-movements of manic-depressive patients does not vary 
 exactly with the degree of depression or of maniacal excitement 
 which they present. On the other hand, it should be noted that 
 there is some variation even among normal persons. In any fair 
 evaluation of our data, then, one must allow at the outset for 
 some individual variations, independent of all disease. The origin 
 of these individual variations is at present a matter of conjecture. 
 Earlier studies (6, 9) demonstrated that the differences between 
 individuals are not absolutely constant for different angles of 
 movement, or for the same angle of movement at different times. 
 But these variations are relatively small, and are due, in part at 
 least, to minor variations in the action of opposed and cooperating 
 muscles which are not further analysed, and which may be 
 grouped together for our purposes as chance variations. But 
 after due allowance is made for these chance variations, the 
 grossness of the variations in the insane and certain very obvious 
 tendencies in different diseases and in different phases of the same 
 disease indicate some causal interdependence with the disease 
 itself. 
 
 While it would be injudicious to regard these tendencies as 
 settled before our data have been materially increased, the marked 
 variations of the extreme maniacal and the extreme depressive 
 states may safely be regarded as characteristic. This appears not 
 merely from Table I, but still more convincingly from the his- 
 tory of such cases as 26, H. N., p. 173 ; 29, R. R., p. 173 ; and 33, 
 K. B., p. 173. So again both patients suffering from dementia 
 praecox and dementia paralytica have abnormally rapid eye-move- 
 ments, while the epileptics are notably long. The slow eye-move- 
 ments of the extreme depressive and the quick eye-movements of 
 the extreme maniacal coincide with the general phycho-motor dis- 
 turbances as they appear in the familiar clinical picture of these 
 psychoses. Quantitative evidence of abnormal quickness of
 
 OCULAR REACTIONS IN THE PSYCHOSES 
 
 175 
 
 maniacal movements has, however, hitherto been conspicuously 
 lacking. On the other hand, it is again congruent with the 
 
 Normal Is 
 
 j. 
 
 
 ':~:::i 
 
 Depressed 29.2 
 
 ■v«* 
 
 r^ 
 
 / 
 
 Paretic 44 
 Plate I 
 
 ] 
 
 Praccox 40 
 
 Plate I is a reproduction of typical records of eye-movements. The 
 records were projected by lantern and drawn from the projected image on a 
 much enlarged scale. These drawings are here reprouced by process on a 
 somewhat reduced scale. The resulting lines reproduce the original records 
 very well, save that the dashes are relatively fainter grey in the records. 
 The exact shape of each dash is not accurately reproduced. In all cases 
 which are represented in Plate I the photographic plate was moving so 
 slowly that the dots run together in the vertical lines, appearing as dashes 
 only during eye-movement. The dashes represent flashes of light succeed- 
 ing each other every o.oi second. The paretic line, No. 44.1, is an extreme 
 case of head-movement and broken lines. The broken movements are 
 typical, the head-movements less so.
 
 1/6 OCULAR REACTIONS IN THE PSYCHOSES 
 
 disease-picture that the eye-movements, which we have found to 
 be rapid, are secondary automatic acts, not those that require 
 conscious direction and control such as have hitherto been meas- 
 ured ; and it certainly corresponds closely with our general knowl- 
 edge of the diffusion of the sensory impulses and the interaction 
 of the higher and lower nervous centers, that these secondary 
 automatic movements should reach their extreme velocity when 
 the interaction of the higher nervous centers is lessened. 
 
 The slowness of the eye-movements in the depressives and in 
 the epileptics cannot be accounted for conversely by excessive 
 interference of the higher centers. It seems rather to be the ex- 
 pression of a more widespread involvement resulting in a gen- 
 eral inefficiency of the whole psychomotor system and including 
 not only the higher centers, which appeared to be chiefly involved 
 in mania, but also the lower centers, the simple reflexes, and the 
 automatic acts. 
 
 Besides the mere differences of velocity in the eye-movements, 
 there are certain characteristic tendencies in form and accuracy of 
 eye-movement that our technique was not designed to measure, 
 but which may be mentioned in passing. Along with the increased 
 velocity in the maniacal eye-movements, there is a parallel tend- 
 ency to abnormal overshoots such as were first described in nor- 
 mal persons by E. B. Huey (3). Depressive eye-movements are 
 more regular and symmetrical. The eye slides up into the new 
 position as though against a gradually increasing resistance. 
 
 The eye-movements of the grossly demented show marked inac- 
 curacies of fixation. Advanced dementia paralytica has curious 
 inconsequential fixations, breaking the normal eye-movements at 
 irregular points. 
 
 2. Ocular Reaction-Time to New Peripheral Stimuli 
 
 The second test concerned the simple reaction of the eye in 
 responding to a peripheral stimulus. Like the first test, the sec- 
 ond also depended on the regular and usually wholly unconscious 
 habit of fixing a numeral or letter one is expected to read. 
 
 (A) Experimental Conditions 
 
 The procedure was as follows : A figure 6 was exposed in the 
 left hand slit of the permanent screen. The subject's attention
 
 OCULAR REACTIONS IN THE PSYCHOSES 1 77 
 
 was directed to it with the instructions that other figures, which 
 would appear at one side or other of the 6, must be read as rapidly 
 as possible. With the final warning to look sharp, the 6 suddenly 
 dropped out of sight and i in. (2.5 cm.) to the right or left there 
 appeared a different numeral. The exposure apparatus resembled 
 that used in the first series of experiments. A special exposure 
 screen was prepared so as to expose one figure (6) at the center 
 of the left hand opening in the permanent screen when the ex- 
 posure screen occupied its primary position. A series of numbers 
 was pasted on pieces of black cardboard which could be slipped 
 into place either to the right or left of the 6 and just so far above 
 it as would bring them into view by one stroke of the escapement. 
 It only required ^ in. (1.25 cm.) movement of the exposure screen 
 to carry the 6 out of sight and to expose the new number. The 
 movement was so rapid that it seemed like an instantaneous 
 change. Without the appearance of motion in any direction, the 
 one seemed to disappear and the other was in place. The same 
 movement of the exposure screen uncovered the arc light and 
 began the photographic record. Simply counting the dashes of 
 which the record was composed from the beginning of the record 
 to the beginning of the eye-movements to fix the new number 
 gave the reaction time of the eye in o.oi second. A similar ex- 
 periment is described more in detail in Dodge's " Experimental 
 Study of Visual Fixation " (8). Vocal reaction to printed matter 
 or to isolated words, such as Dodge studied, seemed inexpedient 
 in these tests on account of gross differences in education. Four 
 ocular reactions were taken for each subject. Unfortunately, in 
 some cases extreme head-movements made some of the records 
 uncertain, while winking made other records useless. These two 
 disturbances combined materially to reduce the number of avail- 
 able records. 
 
 The small number of reactions for any one individual is a 
 serious limitation to the use of our data. If we had the work to 
 do over again, we are agreed that we should venture to increase 
 the number of simple reactions. Our reason for limiting the 
 number in the present tests was the consciousness that we were 
 dealing with subjects who were abnormally susceptible to fatigue 
 of attention. To some of them even four tests of the same 
 
 13
 
 1/8 
 
 OCULAR REACTIONS IN THE PSYCHOSES 
 
 kind seemed many. For the sake of comparison, we ran through 
 a series of ten reactions each with two more tractable cases. The 
 results show that, in these two cases at least, the smaller number 
 did no violence to the facts. In later discussions it will appear 
 that minimal reactions and the general variability are quite as 
 important as the rather meaningless averages. 
 
 (B) Results 
 
 TABLE II 
 
 Simple Ocular Reactions to Periphekal Stimuli 
 
 I 
 
 2 
 
 3 
 4 
 
 I. Normal 
 
 . R.D. ... 
 
 . A 
 
 . Wh 
 
 . Wr 
 
 200 
 20O 
 
 215 
 210 
 
 Average 206 
 
 5 
 6 
 
 7 
 8 
 
 9 
 10 
 
 H. . 
 T. . 
 Wi. 
 C. .. 
 LI. . 
 E.F. 
 
 192 
 249 
 140 
 
 247 
 223 
 
 195 
 
 Average 208 
 
 11 ... W.S 198 
 
 12 ... J. R 225 
 
 Average 211 
 
 2. Mania 
 
 Marked 
 
 13 •••• S. S 205 
 
 14 J. C 210 
 
 217 
 
 16 M. M 225 
 
 17 M. D. (a) . . 250 
 
 18 ..'. . T. S 250 
 
 19 J. G 210 
 
 20 S. K. (&) .. 229 
 
 Average 224 
 
 Less Marked 
 
 31 L. K. (c) .. 260 
 
 21 A. H 215 
 
 27 . . . . M. G. (d) . . 257 
 
 22, .... KB. (&).. 219 
 
 Average 238 
 
 3. Depression 
 
 Marked 
 
 26 ... H.N. (o) 250 
 
 27 ... M. G. ... 295 
 29 ... R.R. (c). 173 
 
 Less Marked 
 32 ... P. F. ... 379 
 
 Slight 
 
 34 • • • T. B 293 
 
 17 ... M. D. (6) 204 
 
 Average 266 
 
 High 379 
 
 Low 173 
 
 17 ... M. D. ... 222 
 Average 222 
 
 Average 209 
 
 High 249 
 
 Low 140 
 
 Hypomania 
 
 22 . . 
 
 .. G. ... 
 
 
 . 230 
 
 23 •• 
 
 .. P. A. 
 
 
 . 225 
 
 20 .. 
 
 .. S. K. 
 
 (c). 
 
 . 202 
 
 24 .. 
 
 .. P. B. 
 
 .... 
 
 . 170 
 
 25 •• 
 
 .. P. R. 
 
 .... 
 
 . 230 
 
 Average 
 
 211 
 
 Average 224 
 
 High 260 
 
 Low Hypo 170
 
 OCULAR REACTIONS IN THE PSYCHOSES 
 
 179 
 
 4. Dementia Precox 
 Marked 
 
 36 ... A. R 240 
 
 37 ■■• M. B 185 
 
 38 ... R.B 258 
 
 Average 228 
 
 Moderate 
 
 39 ... A. McI. .. 276 
 
 41 ... M. F. ... 220 
 
 Slight 
 
 42 ... B. M. ... 152 
 
 Average 222 
 
 High 276 
 
 Low 152 
 
 5. Dementia Par 
 
 alytica 
 
 
 6. Epileptic 
 
 
 Marked 
 
 
 
 Moderate 
 
 
 43 .... D. D. . 
 
 ... 370 
 
 51 
 
 ... G. L. ... 
 
 298 
 
 44 .... W. H. 
 
 ... 237 
 
 52 
 
 ... J. F. ... 
 
 228 
 
 45 .... A. B. . 
 
 ... 225 
 
 53 
 
 . . . H. 0. . . . 
 
 195 
 
 47 .... A. S. . 
 
 ... 237 
 
 54 
 
 . . . M. B. . . . 
 
 197 
 
 Average 
 
 ... 267 
 
 
 
 
 Less Marked 
 
 48 J. P. E. ... 190 Average 
 
 49 .... J. A 217 High ... 
 
 Average 203 Low . . . 
 
 (50 
 
 Remission 
 . F. A. . . . 
 
 Average 
 High . . . 
 Low . . . 
 
 193) 
 
 . 246 
 - 370 
 . 190 
 
 229 
 298 
 195 
 
 (C) Discussion of Table II 
 
 The simple ocular reaction-time is long. According to our 
 records the normal average lies above 2000-. In strict accuracy 
 this average is undoubtedly too high, and should be reduced by a 
 constant instrumental error of about fifteen. This error is in- 
 volved in the form of the exposure of the peripheral stimulus. 
 We have not tried to correct it, since it applies equally for all 
 subjects, and our interest lies mainly in comparative rather than 
 absolute time estimations. But after all corrections are made, 
 these records agree w^ith all the available data, and the simple 
 ocular reaction-time is long. 
 
 One might a priori have expected that a reaction which is at 
 once so common and apparently so necessary to the welfare of 
 the individual in the conduct of life would be short. On the other 
 hand, it must be noted that each ocular reaction to peripheral 
 stimuli involves a considerable sensori-motor elaboration of the 
 stimulus. The adequate reacting eye-movement is not only in a 
 definite direction, but it is also of definite extent. The accuracy 
 of the eye-movement does not now concern us, since we measure 
 in reaction-time only the beginning of the reactive movement. 
 But the beginning of every eye-movement is really only the initial 
 phase of a movement of definite direction and extent. Before
 
 l8o OCULAR REACTIONS IN THE PSYCHOSES 
 
 the eye starts, the elaboration of that particular motor impulse 
 must be relatively complete. An accurate account of the cor- 
 respondence between reaction-time and reaction-accuracy is a 
 desideratum. 
 
 In a sense, every ocular reaction to a peripheral stimulus is not 
 a simple reaction at all, but an individual adaptation to a change 
 in the environment. In the past, such a reaction would have 
 borne the misleading name of a " choice reaction." The length 
 of the simple ocular reaction, then, is not an anomaly. It corre- 
 sponds directly with the complex but automatic elaboration of the 
 sensori-motor impulse. 
 
 Abnormal reactions may result from an indefinite number of 
 changes within this complex sensori-motor process. This is at 
 once the inspiration and the danger of every interpretation of 
 complex reactions. In view of the possible complications, the 
 relatively small mean variation for normal subjects points to a 
 relatively stable normal oculo-motor systematization. It em- 
 phasizes at the same time the gross variations of the insane. 
 
 The small number of per capita records forces us to consider 
 the reactions, as we were led to consider the velocity of movement 
 by groups rather than by individuals. Furthermore, we will 
 again limit our generalizations to such gross variations as are 
 inexplicable on the basis of chance variations. 
 
 The most conspicuous comparative feature of the results is the 
 abnormally long reactions of the maniacal-depressive patients. 
 Not only do they average long, but, with one exception, the aver- 
 age reactions of both the extreme and the less marked maniacal, 
 and of all the depressed with one exception, are above the normal. 
 These data are not novel. They agree with the reaction experi- 
 ments of Franz. 
 
 In view of the unequivocal testimony of the averages, it is 
 somewhat disappointing to note that there is no direct corre- 
 spondence between the duration of the ocular reactions and the 
 clinical judgment of the severity of the disease. It is hardly an 
 accident that in spite of the high averages in cases of mania the 
 most extreme maniacal excitement had the shortest ocular reac- 
 tion; while the maniacal group, which averages the longest, is 
 that of the less marked excitement. In view of the complica- 
 tion of the reaction-process and the number of unanalyzed factors.
 
 OCULAR REACTIONS IN THE PSYCHOSES l8l 
 
 we feel that any hypothesis of the effect of the disease on the 
 reaction must be regarded as tentative. But on grounds which 
 will appear most clearly in the discussion of the pursuit-reactions, 
 we believe that the inconsequential reactions of maniacal excite- 
 ment are due to opposed tendencies in the inter-relation of the 
 superior and the secondary central systematizations. 
 
 3. Ocular Pursuit-Reactions 
 (A) Theory 
 
 The third series of tests was a reaction experiment of unusual 
 character. The simplest and, in the end, also the most complex 
 ocular reaction with which we are acquainted is the pursuit- 
 movement in reaction to moving pendulum. 
 
 It is the simplest, in the sense that no new object of regard is 
 furnished as stimulus for reaction. There is no change in the 
 object of attention. An object is fixed, and the fixation lapses 
 through the movement of the object fixed. The reestablishment 
 of the lapsed fixation involves a form of ocular reaction such as 
 occurs on an average several times a minute throughout the wak- 
 ing day, either because the object moves or because of involun- 
 tary displacement of the eyes by bodily movements. Pursuit- 
 reactions, as we may call them, normally involve a reaction- 
 time slightly longer than the simple reactions to peripheral stimuli. 
 At least one factor tending to lengthen the pursuit-reaction appears 
 directly in the form of the stimulus. The stim.ulus to reaction is 
 not given in the release of the pendulum, but only when, after 
 release, the pendulum has moved some appreciable distance. 
 The amount of movement that will constitute a stimulus to pur- 
 suit will depend on the training of the subject and the accuracy 
 with which he maintains his fixations. 
 
 Paradoxical as it might at first seem, the total pursuit-reaction 
 finally involves more extensive psychomotor elaboration than any 
 other ocular reaction that we know how to produce. As is now 
 well known (Dodge [7]), the true pursuit eye-movements are 
 totally different in function and character from the rapid reaction- 
 movements of the eyes by which peripheral objects of interest 
 are fixated. The rapid movements are relatively constant in 
 duration, and they constitute moments of practical blindness.
 
 1 82 OCULAR REACTIONS IN THE PSYCHOSES 
 
 The reason for this eye-movement bHndness is still under discus- 
 sion. There is no debate concerning the fact. The pursuit- 
 movements, on the other hand, vary in angle-velocity with the 
 angle- velocity of the moving object. The eyes move fast or 
 slowly as the object moves fast or slowly. Moreover, the pur- 
 suit-movements are pre-eminently moments of relatively clear 
 vision. It is because we wish to see an object clearly that we 
 move the eyes as the object moves and keep its image on retinal 
 areas of relatively clear vision. Furthermore, the psychomotor 
 elaboration of the simple ocular reaction is fixed by the long- 
 established habit of bringing excitations of the peripheral retina to 
 areas of clear vision. The psychomotor elaboration of the pur- 
 suit-movements, on the other hand, is in practically each instance 
 of pursuit an unique psychomotor problem. The reaction to 
 pursuit is fixed and habitual enough, but the velocity of the eye 
 which shall correspond to the velocity of the object at the distance 
 it chances to be can scarcely ever be a motor habit. To be a suc- 
 cessful pursuit there must be an adaptation of the general pursuit 
 tendency to the peculiar condition of each separate instance. 
 Especially in the pendulum pursuit-movements are these condi- 
 tions so various as to present, in each new case, practically unique 
 conditions. Angle-velocity, apparent amplitude, and period of 
 oscillation would all be alike only if pendulums of the same length 
 swing through the same arc at the same distance from the eye of 
 the observer. Yet unique as each case actually is, a normal eye 
 will fall into an adequate pendulum pursuit-movement with sur- 
 prising quickness and accuracy. In every normal individual the 
 very first fixation after the initial reaction to a moving pendulum 
 has the characteristic true pursuit-slide, even though it usually 
 corresponds in angle-velocity to the first part of the pendulum 
 swing, and is consequently too slow. Let us emphasize the fact : 
 for normal individuals, however inadequate the first attempt to 
 fix the moving object may be, it always has the characteristics of 
 a true pursuit-movement (see Plate, lines i, lo, ii). 
 
 The return swing of a second pendulum is usually followed 
 with precision, except at or near the middle of the arc of oscilla- 
 tion, when one or two short, sharp, rapid movements break the 
 simple pendulum pursuits. The character of these pendulum 
 pursuits scarcely alters, even after a large number of experiments
 
 OCULAR REACTIONS IN THE PSYCHOSES 1 83 
 
 under the same objective condition. Each new pursuit seems to 
 be solved de novo, and the short-lived motor habits involved in 
 every adequate pursuit seem to be lost when the pursuit is inter- 
 rupted (8). 
 
 This ability to elaborate adequate pursuit-movements, i. e., to 
 adopt an adequate motor response to the peculiar situation pres- 
 ented by the rhythmic movements of an object, varies widely in 
 mental disease. In some respects, the most marked variations are 
 found in the pendulum pursuit-movements in dementia praecox, 
 where a marked hesitation to fall into the swing of the pendulum 
 was found even in the mildest cases. While this peculiarity is ap- 
 parently not absolutely restricted to dementia praecox, it was 
 found in other patients only where the disease-process has pro- 
 duced marked deterioration. 
 
 (B) Experimental Conditions 
 
 The instrumental device for producing the pursuit-reaction and 
 the subsequent pursuit-movements was a number attached to the 
 bob of a second pendulum. The latter hung just in front of the 
 fixed screen with its axis vertically above the middle point 
 between the extreme left and right hand opening. Before the 
 experiment the pendulum was held out of equilibrium in front 
 of the left hand opening by a simple catch attached to a falling 
 screen in the usual place behind the fixed screen. This falling 
 screen was released by the operator, as in the other experiments, 
 and the release of the screen simultaneously started the pendu- 
 lum and opened the way for the recording beam of light. In 
 every case the patient was previously shown how the pendulum 
 moved and was then requested to watch the number closely, to 
 keep his eyes on it, not to lose it, watch it, &c.
 
 1 84 
 
 OCULAR REACTIONS IN THE PSYCHOSES 
 
 Ocular 
 I. Normal 
 
 (C) Results 
 TABLE III 
 
 Reactions in Pursuit of a 
 2. Mania 
 
 Moving Stimulus 
 
 3. Depression 
 
 1 ... R.D. 
 
 2 ... A. . 
 
 3 ... Wh. 
 
 4 ... Wr. 
 Average . . . 
 
 5 
 6 
 
 7 
 8 
 
 9 
 10 
 
 H. .. 
 T. ., 
 Wi. . 
 C. ., 
 LI. ., 
 E.F. 
 
 Average 
 
 11 ... W.S. 
 
 12 ... J. R. 
 Average . . . . 
 
 17 
 
 M. D. 
 
 Average 
 High . . . 
 Low . . . 
 
 198 
 233 
 243 
 210 
 221 
 
 274 
 284 
 216 
 225 
 26s 
 285 
 258 
 
 235 
 223 
 229 
 
 223 
 
 239 
 285 
 198 
 
 13 
 14 
 
 Marked 
 S. S. ... 
 J.C. ... 
 
 M. M. 
 T.S. . 
 J.G. . 
 S.K. . 
 
 16 . 
 
 18 . 
 
 19 . 
 
 20 . 
 Average 
 
 Less Marked 
 31 .... L.K. (c) .. 
 
 21 .... A. H 
 
 27 .... M. G. (c-d) 
 33 .... K.B. (&) .. 
 Average 
 
 Hypomania 
 
 . G 
 
 . R. R. (a) . . 
 
 . P. A 
 
 . S.K. (c) .. 
 
 . P. B 
 
 . P.R 
 
 22 
 29 
 
 23 
 20 
 
 24 
 
 25 
 
 Average 
 
 Average 
 
 High (marked) 
 Low (Hypo) . . . 
 
 190 
 225 
 222 
 
 343 
 217 
 
 225 
 
 314 
 248 
 
 260 
 217 
 305 
 
 255 
 259 
 
 210 
 220 
 240 
 212 
 155 
 273 
 218 
 
 240 
 
 343 
 155 
 
 4. Dementia Precox 5. Dementia Paralytica 
 
 36 . 
 
 37 ■ 
 
 39 ■ 
 
 40 . 
 
 41 . 
 
 Marked 
 . A.R. ... 
 . M. B. . . . 
 
 Moderate 
 . A. McL . 
 . G.L. ... 
 . M. F. . . . 
 
 Slight 
 42 ... B. M. . 
 
 Average 
 
 High 
 
 Low 
 
 30s 
 195 
 
 207 
 260 
 
 215 
 
 275 
 243 
 305 
 195 
 
 Marked 
 
 43 ..•• D.D 
 
 44 • ■ . . W. H 
 
 45 ■•.. A.B 
 
 47 .... A. S 
 
 Less Marked 
 
 48 .... J. P. E 
 
 Average 
 
 High 
 
 Low 
 
 Average excluding 
 high 
 
 445 
 240 
 224 
 267 
 
 227 
 
 281 
 
 445 
 224 
 
 239 
 
 Marked 
 
 27 ... M. G 379 
 
 28 ... M. C 255 
 
 29 ... R. R. (c). 230 
 
 30 . . . L. W. ... 339 
 
 Average 
 
 301 
 
 Less Marked 
 Slight 
 
 34 ... T. B 303 
 
 17 ... M. D. (b) 272 
 Average 287 
 
 Average 
 High ... 
 Low . . . 
 
 296 
 
 379 
 230 
 
 6. Epileptic 
 
 Moderate 
 
 .. G.L. . 
 
 .. J.F. .. 
 
 . . H. O. , 
 
 . . M. B. . 
 
 51 
 52 
 53 
 54 
 Average 
 
 280 
 222 
 230 
 221 
 238
 
 OCULAR REACTIONS IN THE PSYCHOSES 1 85 
 
 TABLE IV 
 Table of Comparison of Avekages 
 Normal Depression Dementia Paralytica 
 
 Mvt. Reactions Pu^^"''- Marked Marked 
 
 reactions t> ■ p • 
 
 59 .... 209 .... 239 Mvt. Reactioss P^";=;j,'^; Mxt. Reactions P™^", 
 
 69 239 301 57 •■ . • 267 .... 294 
 
 Mania 
 
 Marked Less Marked and Slight Total 
 
 54 224 248 61 295 287 55 246 .... 281 
 
 Less Marked Dementia Precox Epileptic 
 
 55 238 259 Moderate, Marked and 69 .... 229 — 238 
 
 Slight 
 
 Hypomania 56 222 243 
 
 62 211 .... 218 
 
 (D) Discussion of Table III 
 
 In all classes except in moderate depression the pursuit-move- 
 ment reaction averages longer than the simple ocular reaction. 
 The differences between the two, however, are not constant. Even 
 in the group of normal persons the differences are not constant. 
 The variations, however, allow of some degree of classification. 
 It must be remembered that the stimulus to pursuit-movement is 
 not mechanically fixed as was the stimulus to a new peripheral 
 stimulus. The movements of the pendulum operate as a stimulus 
 to pursuit only when the lapsed fixation in some way makes itself 
 felt through the indistinctness of the object. For the trained 
 observer it operates almost immediately. For the less trained 
 it operates only after the pendulum has moved some clearly ap- 
 preciable distance. The mean difference between pendulum- and 
 pursuit-reactions for normal observers under the conditions of 
 our test was approximately 300-. This average difference holds 
 approximately the same for praecox and for the longer reactions 
 of paresis. It does not hold for maniacal-depressives. But the 
 individual variations are so great that the maniacal-depressive dif- 
 ferences can scarcely be spoken of as characteristic. It does, 
 however, constitute additional evidence of a high degree of dis- 
 turbance of those complex superior central processes which are 
 usually grouped under the general name of attention. Further 
 evidence to the same effect comes from a consideration of minimal 
 reactions, which are given in Table V.
 
 i86 
 
 OCULAR REACTIONS IN THE PSYCHOSES 
 
 I 
 2 
 3 
 4 
 5 
 6 
 
 7 
 8 
 
 9 
 
 10 
 
 II 
 
 12 
 
 17 
 
 Normal 
 ,. i8o ... 
 . . i8o ... 
 , . 2o6 . . . 
 
 . . 200 . . . 
 
 ,. i66 ... 
 
 230 
 128 
 
 243 
 200 
 180 
 140 
 210 
 220 
 
 180 
 200 
 230 
 200 
 260 
 273 
 179 
 179 
 240 
 260 
 200 
 
 2X0 
 190 
 
 Average 191 216 
 
 Dementia Precox 
 
 TABLE V 
 Table of Minimal Reactions 
 Mania 
 Mania 
 
 13 180 180 
 
 14 180 180 
 
 16 186 257 
 
 17 205 
 
 18 210 200 
 
 19 160 210 
 
 20 182 257 
 
 186 214 
 
 31 230 240 
 
 21 190 210 
 
 27 230 280 
 
 33 190 190 
 
 210 230 
 
 22 210 200 
 
 23 210 200 
 
 20 190 200 
 
 24 ISO 140 
 
 25 210 220 
 
 194 192 
 
 Average. 19S 211 
 
 Dementia Paralytica 
 
 36 
 
 38 
 39 
 40 
 
 41 
 42 
 
 200 
 180 
 248 
 260 
 
 200 
 ISO 
 
 260 
 190 
 
 167 
 240 
 180 
 230 
 
 43 
 44 
 45 
 47 
 48 
 49 
 SO 
 
 •350 
 220 
 210 
 230 
 170 
 180 
 180 
 
 Average 206 211 Average. 220 
 
 290 
 200 
 210 
 240 
 210 
 
 230 
 
 26 
 
 27 
 28 
 28 
 
 Depression 
 
 200 
 
 ..-. 279 244 
 
 228 
 
 . . 170 210 
 
 216 227 
 
 34 240 300 
 
 17 (fe).. 186 248 
 
 213 274 
 
 Average 215 246 
 
 51 
 
 52 
 53 
 54 
 
 Epileptic 
 
 . . 270 250 
 
 , . . 200 200 
 
 ,. . 190 210 
 
 ... 170 200 
 
 Average 207 215 
 
 Discussion of the Table of Minimal Reactions (Table V) 
 
 In some respects the minimal reactions for any well-established 
 type of reaction is more instructive than the average reaction. 
 The minimal reaction shows the reflex systematization in its 
 highest state of efficiency. The mean reaction indicates the 
 average state of efficiency. The two differ from one another by 
 the mean value of all those disturbing elements that may com- 
 plicate the reaction-process. It seems to the writers a very sig- 
 nificant fact that the average minimal reaction of extreme mania-
 
 OCULAR REACTIONS IN THE PSYCHOSES 1 8/ 
 
 cal excitement is below the average minimum of normal subjects. 
 It is not much below the normal, but it is not above it as the 
 total average is. Moreover, the mean variation of the minimal 
 reactions is approximately the same as the mean variations of the 
 averages. This consistent uniformity is not accidental. In con- 
 nection with the adequate pursuit-reactions it seems to the writers 
 to constitute unequivocal evidence that the oculo-motor systemat- 
 ization is not seriously disordered in acute mania. The large 
 mean value of disturbing elements constitutes the final point that 
 we have to offer in the cumulative experimental evidence that 
 extreme mania involves a marked disturbance of the controls 
 normally exercised by the superior central systematizations. 
 
 This seems to the writers to coincide closely with the general 
 clinical picture of marked mania. The motor organization even 
 for complex acts is not lost. The incapacity for regular employ- 
 ment is flagrantly due to gross disturbances of the normal con- 
 trols within the higher systematizations. Tentatively, at least, we 
 may picture this in terms of an inhibition of the free interaction 
 of the various factors in the normal complex superior organiza- 
 tion. 
 
 Provided there is some intrinsic retardation of the intermediate 
 systematizations, like the simple oculo-motor reflexes, we should 
 expect to find the total evidences of maniacal excitement less 
 marked. In such cases we should expect the minimal reactions to 
 be long as well as the average reactions. This is actually the case 
 in less marked mania. It looks as though the inhibitory processes 
 involved in the disease were affecting lower centres. The climax 
 of this downward progression seems to be reached when, in 
 extreme depression, the resistance to neutral interaction involves 
 the simplest reflexes. 
 
 In contrast to the differential increase of resistance to neural 
 activity as found in the manic-depressives, our experimental data 
 from the demented point to a general disorganization of the 
 central systematizations. 
 
 In dementia paralytica the entire nervous system is involved in 
 this disorganization, as is shown by the marked retardation, and 
 the inefficiency of the simplest, as well as of the higher reflexes 
 (patellar, pupillary, and cerebellar). 
 
 In prcTCOx the disorganizations seem to be primarily limited to
 
 1 88 OCULAR REACTIONS IN THE PSYCHOSES 
 
 the superior systematizations. This is shown negatively by the 
 rapid eye-movements, normal oculo-motor reactions, and posi- 
 tively by the difficulty of adopting adequate reactions to new 
 conditions of the environment, as in the pursuit-movements. 
 This latter peculiarity of prsecox patients has a practical as well 
 as a theoretical interest. 
 
 Practically, it is an important differentiating symptom between 
 moderate maniacal excitement and developing prsecox, i. e., be- 
 tween two psychoses whose differential diagnosis is of the utmost 
 importance and often of the utmost difficulty. Unfortunately the 
 faultiness of the pursuit is not easily detected by direct observa- 
 tion. Photographic registration, although remarkably simple as 
 a scientific technique, is rather too expensive in time and appa- 
 ratus for regular professional use. If the matter prove worth 
 while, a simplified recording apparatus is probably the only safe 
 and practicable solution. It would seem strange, however, if 
 similar phenomena cannot be found in other forms of reaction 
 which are more accessible to direct observation. 
 
 The theoretical bearing of the inadequate ocular pursuit-move- 
 ments of prsecox we have already mentioned. It was not over- 
 looked by us that the simplest explanation of the phenomenon 
 would be to coordinate it with those processes which are ordi- 
 narily grouped under the head of faulty attention. This ex- 
 planation seems to us untenable on the following grounds : 
 
 1. Equally grave defects of "attention" exist in maniacal ex- 
 citement without parallel difficulty of pursuit. 
 
 2. The reaction-times do not indicate gross defects of " atten- 
 tion " in moderate prsecox. 
 
 3. Reasonable " attention " and effort at pursuit are both clearly 
 indicated in the number and character of the short corrective 
 movements. 
 
 Finally, the phenomenon seems to connect itself naturally with 
 certain characteristic clinical observations of prsecox as one man- 
 ifestation of the patient's inability to adapt himself to new and 
 unusual requirements of his environment. Put technically, it is 
 the patient's inability to adopt adequate short-lived habits in 
 response to a new recurrent situation. There is some clinical 
 evidence that this motor phenomenon rests on a basis of faulty 
 elaboration of the perceptual data. Our experiments indicate
 
 OCULAR REACTIONS IN THE PSYCHOSES 
 
 189 
 
 : '. \ ! \ .. \ •. •. 
 
 \ \ \ \ \ / \ \\ 
 
 I / 
 
 ' i : 
 
 i t 
 
 I t 
 
 i I 
 
 n 
 
 i 
 
 I f I ; / 
 
 /(J ff 
 
 no 11 14 20 25 25 54 34- 36 41 
 
 Normal Mania Depressed Praccox 
 
 Plate II 
 
 I r 
 
 \\ 
 
 I \ \ \ 
 
 1 in 
 
 
 y / 
 
 I M / 
 
 ^ : 
 C : 
 
 43 43 47 48 51 52> 52 
 D.Paralylica Epileplics 
 
 Plate II is reproduced from drawings of typical pursuit-reaction records. 
 It shows most of the typical variations of the visual pursuits so far as 
 they were not complicated by gross head-movements. The lines accurately 
 reproduce only the general configuration of the pursuit. 
 
 Each line, reading from the bottom up, represents one complete pursuit- 
 swing corresponding to a double oscillation of the second pendulum. Since 
 the release of the pendulum and the beginning of the record are synchron- 
 ous, the straight line at the beginning of each record gives the reaction- 
 time. The reaction begins with a sharp horizontal movement to the right. 
 This is followed by the slow pursuit swing, which is more or less ade- 
 quate according to the nature of the disease. The praecox pursuits, nos. 
 36 and 41, are typical. In mild cases the hesitation to adopt the pursuit- 
 swing is less pronounced, but it is regularly shown by straight lines some- 
 where in the pursuit. The maniacal pursuit shows a tendency to get ahead 
 of the pendulum (see upper part of lines 14, 23 and 25). This tendency 
 sometimes appears in the first positive acceleration of the pendulum in 
 maniacal cases. It is not entirely absent from normal pursuits or from 
 moderate depression. In the latter cases, however, it is very rare. Other 
 modifications of the pursuit are suggestive, but at present they permit no 
 generalized statement. 
 
 The double breaks in each record are occasioned by the swinging of the 
 pendulum through the recording beam of light.
 
 190 OCULAR REACTIONS IN THE PSYCHOSES 
 
 that the intellectual defect is a matter of inadequate appreciation 
 rather than a matter of attention. 
 
 The writers take the opportunity to express to Dr. H. S. Noble, 
 superintendent of the Connecticut Hospital for the Insane, their 
 cordial appreciation of his sympathetic interest and encourage- 
 ment which made this series of experiments possible. 
 
 The appendix containing a brief account of each case by Dr. 
 Diefendorf, together with all the experimental comparative data 
 from the photographic records, may be consulted in original 
 article. Brain, CXIII, 1908. 
 
 BIBLIOGRAPHY 
 Mechanical Registration of the Eye-Movements 
 
 1. Delabarre, E. B. "A Method of Recording the Eye-Movements," 
 
 Amer. Joura Psych, Vol. IX, pp. 572-574. 
 
 2. Huey, E. B. " Preliminary Experiments in the Physiology and 
 
 Psychology of Reading," Amer. Journ. Psych., Vol. IX, pp. 575-586 
 
 3. Idem. " On the Physiology and Psychology of Reading," Amer. 
 
 Journ. Psych., Vol. XI, pp. 283-302. 
 
 Photographic Registration of the Eye-Movement 
 
 4. Cameron, E. H., and Steele, W. M. "The Poggendorflf Illusions," 
 
 Yale Studies, Vol. I, No. i, pp. 83-in. 
 
 5. Dearborn, A. F. "Retinal Local Signs," Psych. Rev., Vol. XI, pp. 
 
 297-307. 
 
 6. Idem. " The Psychology of Reading," Arch. Philos., Psych., and Sci. 
 
 Method, No. 4. 
 
 7. Dodge, R. " Five Types of Eye-Movement in the Horizontal Meridian 
 
 Plane of the Field of Regard," Amer. Journ, Physiol., Vol. VIII, 
 
 pp. 307-329. 
 
 8. Idem. " An Experimental Study of Visual Fixation," " Studies from 
 
 the Psych. Lab. of Wesleyan Univ.," Vol. I, Psych. Rev. Monograph 
 Supplements, Vol. VIII, No. 4. 
 
 9. Idem and Cline, T. S. "The Angle- Velocity of the Eye-Movements," 
 
 Psych. Rev., Vol. VIII, pp. 145-157. 
 TO. Holt, E. B. " Eye-Movements during Dizziness," " Harvard Psycho- 
 logical Studies," Vol. II, pp. 57 fol. 
 
 11. Judd, C. H. "The Miiller-Lyer Illusion," Yale Studies, Vol. I, No. i, 
 
 pp. 55-82. 
 
 12. Idem. " Photographic Records of Convergence and Divergence," 
 
 Yale Pbychological Studies, Vol. I, No. 2, pp. 370-423, Psych. Rev. 
 Monograph Supplement, Vol. VIII, No. 3. 
 
 13. Idem and Courten, H. C. " The Zoellner Illusion," Yale Studies, 
 
 Vol. I, No. I, pp. 1 12-140.
 
 OCULAR REACTIONS IN THE PSYCHOSES I9I 
 
 14. Idem, McAllister, C. N., and Steele, W. M. " Introduction to a Series 
 
 of Studies of Eye-Movements by means of Kinetoscopic Photog- 
 raphs," Monograph Supplement of the Psych. Rev., Vol. VII, Yale 
 Psychological Studies, Vol. I, pp. 1-16. 
 
 15. McAllister, C. N. "Fixation of Points in the Visual Field," Yale 
 
 Studies, Vol. I, No. i, pp. 17-54. 
 
 16. Stratton, G. M. " Eye-Movements and the Esthetics of Visual Form," 
 
 Philos. Studien, Bd. XX, S. 336.
 
 CYCLOTHYMIA— THE MILD FORMS OF MANIC- 
 DEPRESSIVE PSYCHOSES AND THE MANIC- 
 DEPRESSIVE CONSTITUTION 
 
 By Smith Ely Jelliffe, M.D., Ph.D. 
 
 ATTENDING NEUROLOGIST, CITY HOSPITAL ; CLINICAL PROFESSOR OF PSYCHIATRY, 
 
 FORDHAM UNIVERSITY 
 
 The history of the development of the concept of a manic- 
 depressive psychosis is one of the most striking of comparatively 
 modern psychiatric generalizations. 
 
 The generalization that general paresis was, in the mental realm, 
 a disease entity, in the final fashioning of which Falret Sr.^ played 
 so important a part, naturally led the alienists of the times to 
 search for other types which from the same standpoint of entity 
 as to clinical picture might offer permanency to the then rapidly 
 disintegrating systems of Pinel and Esquirol. 
 
 The meed of praise given to Kahlbaum for his insistence on 
 the study of clinical pictures as a whole, and which has enriched 
 our present psychiatric museum with such species and pseudo 
 species as hebephrenia, catatonia, etc., has perhaps been exagger- 
 ated. Kahlbaum was far from being the first advocate of this 
 slogan, so vigorously uttered by the present day school. Falret 
 Sr.'s writings are many and unequivocal on this point, and ante- 
 date Kahlbaum's paper on the Grouping of Mental Diseases. In 
 his Principles of Classification, i860, the newer and broader stand- 
 point is shown throughout, and in his delightful and valuable 
 (even for the purposes of present day psychiatry) discourse on 
 Folic Raisonnante (January, 1866) one finds him stating again 
 and again that psychiatry has suffered too much from the follow- 
 ing of kaleidoscopically varying symptom pictures, regardless of 
 the clinical course. 
 
 It was this clear view of what must be borne in mind, in order 
 to posit a psychosis of itself that led him to the amplification and 
 
 ^Recherches sur la folic paralytiques et !es divcrses paralysies generales. 
 These Inaugurale. Paris, May 30, 1853. 
 
 14 193
 
 194 CYCLOTHYMIA 
 
 the clearer precision of " folic circulaire " as it had been originally 
 described by his father and Baillarger in 1854.^ 
 
 His father and himself, writes Jules Falret,^ have had the rare 
 opportunity to have been able to observe in three different families 
 the existence of this form of mental disease perpetuated in three 
 generations ; the grandmother, mother and daughter, and all with 
 the same form. 
 
 A point of interest historically is that Falret, Jr., used the terms 
 "mixed states " (p. 619) in his paper on folic circulaire, but gives 
 no characterization of what he meant other than transitional 
 periods between successive phases. 
 
 The point of present active interest concerns itself with Jules 
 Falret's clear recognition of the attenuated types of his folic 
 circulaire. It will prove of interest to gather here what this 
 author says of them. Later they may be compared with contem- 
 poraneous German ideas. Falret first states that (p. 602, fitudes 
 Cliniques, 1890) folic circulaire is (as defined) an hereditary 
 affection, and generally found in a similar form in both ascendants 
 and descendants. Speaking of attenuated forms observed in the 
 world at large (p. 604, 1. c.) he says, " In the first place there is a 
 first category of facts which it is of importance to point out above 
 all from the point of view of practical psychiatry and of juris- 
 prudence. One does not often enough appreciate, and certainly 
 one cannot too often repeat that one frequently observes, both in 
 the family circle and in society at large individuals who are not 
 considered as sick, even less as mentally afflicted, and whose en- 
 tire lives are passed, isolated for the most part by the people 
 who surround them in a successive round of periods of moderate 
 excitement and of slightly pronounced melancholy, and who are 
 in reality afflicted in an evident degree, but more attenuated, with 
 this form of mental malady. They continue to live the life of the 
 community, or the family life without its being necessary to treat 
 them as sick individuals, even quite far from considering them as 
 having a psychosis, and above all of shutting them up in asylums. 
 So much so that, when in a period of excitement, these individ- 
 uals simply appear to have changed their character, and to have 
 
 " See also J. P. Falret. La Manie sans delire. These, 1849. J. P. 
 Falret: Gaz. de Hop., 1851. 
 
 ^La folie circulaire. Arch. Gen. de Med., Dec. 28, 1878. Jan., 1879.
 
 CYCLOTHYMIA 1 95 
 
 momentarily acquired an unaccustomed activity. They occupy 
 themselves with business; they make numerous visits, they write 
 letters to those that they are not in the habit of visiting frequently ; 
 they have a desire to be incessantly on the move ; they sleep very 
 little, make numerous trips or projects. They take up, with 
 feverish activity, the duties of their profession, or even take up 
 new business schemes which they seek to advance to a state com- 
 parable with their habitual occupations. They show, on all occa- 
 sions, an exaggerated gaiety. They show themselves to be intel- 
 ligent, loquacious, and even spiritual, and although there may be 
 always present great disorder in their acts, and a certain discon- 
 nectedness in their speech, those who have not known them for 
 some time, or those who have not observed them at other times, 
 are unable to judge of their true mental situation, although the 
 diseased nature of this state does not escape an attentive observer, 
 and is often appreciated with exactness by the members of their 
 families or by those who live habitually with them. 
 
 This diseased character then manifests itself otherwise when 
 after a more or less prolonged period of excitation, which has 
 passed for a simple change of character, there supervenes little 
 by little, or all at once in those individuals who, up to then, had 
 shown gaiety and an exaggerated activity, a state precisely the 
 reverse, to such a degree that one would believe they had to do 
 with two different individuals. Instead of showing this exuberant 
 activity which seems to feel neither fatigue nor the need for rest, 
 these patients cease to go out, to make calls, to do business. They 
 change their character completely : they become sedentary, incom- 
 municative, almost mute ; they flee from the world, seek solitude 
 and isolation ; speak little, or reply briefly to questions addressed 
 to them, complain of general malaise, of a very sad state of suf- 
 fering, of praecordial anxiety, of loss of appetite; they are sad, 
 unhappy, anxious without reason, or for slight occasion. They 
 are conscious of their own condition and regret it, but cannot be 
 brought to modify them ; they thus come to acquire a distaste for 
 living, to refuse food, and in extreme cases, they shut themselves 
 up in their rooms for several months ; without attracting in a 
 notable manner the attention of those about them, especially when 
 one knows that they are the subjects of what one vulgarly calls 
 " black humors," " the blues."
 
 196 CYCLOTHYMIA 
 
 As to the public, they see these people only from time to time, 
 and have no occasion to see them when they are shut up at home ; 
 they cannot doubt the diseased state in which they are found for 
 several months, and when they see them appear later at a time 
 when the period of excitation surges up, they then refind them 
 such as they had known them before. They think of them as 
 eccentric characters, gay and lively, and of feverish activity such 
 as they have observed with certain individuals, but they do not 
 suspect the existence of a morbid state which is appreciable only 
 by the successive reproduction of periods of excitation and of 
 depression which the world is not called upon to determine. 
 
 Such is the lightest and the most often overlooked phase of 
 folic circulaire, the observation of which rarely obtains within 
 hospitals for the insane. 
 
 Falret then discusses the severer grades of folic circulaire, such 
 as are observed in the asylums. 
 
 That psychoses showing periodic attacks have been recognized 
 for centuries will admit of no question, yet I cannot permit this 
 opportunity to go by without calling in question the hasty gen- 
 eralization that has been widely spread, and supported by so good 
 a student of historical problems as Farrar,* that Aretaeus was 
 really the father of manic-depressive insanity. Aretaeus never 
 dreamed of anything like the modern conception. This no one 
 will doubt, and only by reason of a definite misinterpretation of 
 the words " mania " and " melancholia," and a failure to realize 
 what these words meant to writers of the early centuries, has per- 
 mitted such an erroneous impression to originate. 
 
 In a short note on Hippocratic psychiatry,^ I have again called 
 attention to what has long been known, that the ancients did not 
 use the words mania and melancholia in any sense as we now 
 employ them. Melancholia was not at all synonymous with de- 
 pressive conditions as a whole. It was used to designate at times 
 the wildest excitement, and mania was used more as synonymous 
 with insanity, craziness, etc., than it was with excitement. Thus, 
 for instance, the word, used so frequently by Aretaeus, mania- 
 melancholia, is interpretable only as a melancholic insanity, and 
 might have included some excitements as well as some depres- 
 
 * Some Origins in Psychiatry, Am. J. of Insanity, 1909. 
 ^ Alienist and Neurologist, Feb., 1910.
 
 CYCLOTHYMIA 1 97 
 
 sions. In the passages so frequently quoted as substantiating the 
 claim that Aretaeus noticed the periodic change from mania to 
 melanchoHa, it strikes me it has been entirely overlooked that he 
 is discussing the vexed question of the relation of hypochondria 
 to a depressed melancholia, and all that his descriptions really say 
 is that a hypochondria passes over into a depressed melancholia. 
 So much for the early analogies with the idea of manic-depressive 
 insanity. I shall hope to discuss this more fully later, but any one 
 who will read Arnold's historical notes, particularly as applied to 
 Aretaeus, will perceive that he at least had not been misled into 
 assuming that the ancients used the symbols mania and melan- 
 cholia as we use them to-day. 
 
 But this is a pure digression into the historical realm. I wish 
 to assume the reality of so clear a syndrome as to permit us to 
 posit the belief in a manic-depressive psychosis. Not that every- 
 thing now thought of as belonging to this psychosis will ultimately 
 find a resting place there, but that there is a nucleus in the con- 
 stellation that is a mental disorder in as definite a sense as paresis 
 is a disorder, or that there is a dementia praecox nucleus as well. 
 
 Personally the word cyclothymia seems to be a useful one, not 
 perhaps strictly in the sense as first proposed by Kahlbaum, but 
 as a concept expressing one of two things, or both ; namely, mild 
 grades of the manic-depressive psychosis, and the constitutional 
 features that underlie such personalities. In the former sense it 
 has received much attention from the hands of modern writers, 
 particularly Willmans, and in the latter has achieved some popu- 
 larity in France at the hands of Deny, and more particularly by 
 Kahn.« 
 
 The work of Falret, which can never be overlooked in the his- 
 tory of the development of the ideas of the manic-depressive 
 psychosis, cannot now be reviewed, but a brief glance at Kahl- 
 baum's original paper may be of interest. Kahlbaum, it will be 
 recalled, had already given the concepts hebephrenia and cata- 
 tonia somewhat as in their modern cast. In his paper on cyclical 
 insanity'' he adopts Falret's idea of a cyclical psychosis as one of 
 the most settled features in psychiatry, comparing it in definite- 
 ness with paresis and epilepsy. He speaks of it as extremely 
 
 ' Cyclothymia, 1909. 
 
 ^ Ueber cyklisches Irresein. Breslauer aerztliche Zeitschrift, 4, 1882.
 
 198 CYCLOTHYMIA 
 
 common, and as occurring also in such mild grades as rarely to 
 come to the attention of asylum physicians. He defines cyclical 
 insanity in the conventional manner of periodic attacks of excite- 
 ment and depression, following one another with real or apparent 
 sound intervals, and with a certain uniformity in the symptom 
 picture. He calls attention to the apparent anomaly of the alter- 
 nating or periodic occurrence of two such strikingly different 
 types of mental disorder as a part of what apparently is a single 
 disease process, marked by a definite chronicity. He then speaks 
 of these, not as two separate disease forms, but as two stages 
 occurring in the same disease. Kahlbaum (p. 218, 1. c.) is in- 
 clined to believe that these manic and melancholic stages are dif- 
 ferent from what he would term ordinary or classical manias and 
 melancholias, and gives some interesting differentials which need 
 not detain us at present. 
 
 The manic phase of cyclical insanity differs even more from 
 classical mania than does the depressive phase from melancholia. 
 The folic raissonante of the French expresses best the manic 
 phase of the disorder. 
 
 After a somewhat lengthy disquisition on philosophical prin- 
 ciples, Kahlbaum returns to the question of prognosis, and on the 
 basis of a relatively good prognosis on the one hand and the devel- 
 opment of a secondary dementia on the other, he would divide 
 the cases of cyclical insanity into two groups, which really should 
 be considered as things quite different one from another. On the 
 one hand one has a partial disturbance of the mind, a primary 
 disorder of the feelings, a true emotional disorder, the other is a 
 total disorder, affecting all three portions of the soul life, intellect, 
 will, and feelings, and results in degeneration. Vesania typica 
 circularis he proposes to call the latter, and he coins the word 
 cyclothymia (Cyclothymic, p. 221, 1. c.) for the former. 
 
 A true depression remaining as such, and not a depressed phase 
 of a circular insanity, he terms with Fleming a dysthemia, while 
 a manic state is a hyperthemia. Thus the simple emotional psy- 
 choses are dysthemia and hyperthemia, and their combination a 
 cyclothymia. Kahlbaum apparently never developed his ideas 
 further, and gives no detailed description. 
 
 Hecker, Kahlbaum's follower, seemed to take up the same task 
 as he undertook in the case of hebephrenia, namely, that of popu-
 
 CYCLOTHYMIA 1 99 
 
 larizing his teacher's early descriptions, for some sixteen years 
 later in a paper on Die Cyclothymie, eine circulare Gemiithser- 
 krankung,^ he adopts Kahlbaum's term and discusses its symptom- 
 atology, differential diagnosis, and treatment. 
 
 Hecker first acknowledges his indebtedness to Kahlbaum and 
 accentuates the nondementing feature that should characterize 
 cyclothymia from others of the periodic psychoses. Cyclothymia 
 is solely an alternation of a dysthemia and a hyperthemia indicat- 
 ing variations in the emotional tone of the patient with intact intel- 
 lectual faculties. Here it may be noted that Hecker calls attention 
 to Kraepelin's tentative adherence to Kahlbaum's general thesis. 
 
 Hecker makes the acute observation that whereas the depressive 
 phases in the cycle fall under the ban of suspicion as psychotic, 
 it is only rarely that the milder excited periods are recognized as 
 pathological. Hence the astonishing number of periodic depres- 
 sions which are noted and described in psychiatric literature, but 
 a dearth of periodic mild excitements. He writes that in ordinary 
 practice they are diagnosed as neurasthenics. At present we find 
 them largely parading under the more modern symbol psychas- 
 thenia. The patients are for the most part treated for their fan- 
 cied physical ailments. 
 
 The chief and fundamental symptom of the depressive stage of 
 cyclothymia is the psychical retardation with absence of all delu- 
 sions or hallucinations associated with an intense and definite, 
 even though not always correct, insight. The patients complain, 
 in the first place, and continuously, of their loss of ability to do 
 mental work. They have the feeling that they will never be able 
 to do any more work, and that they do everything upside down ; 
 of their indifference to persons and things which had been of great 
 interest to them. They describe their condition as an inward 
 hardening, a stoniness, as though there were a curtain, a wall, 
 or what not between them and the world. Every resolution is 
 difficult, all action an affliction. They must be pushed to accom- 
 plish anything; prefer to be left alone, and reject the overtures 
 of friends because it may be necessary to talk to them. Many 
 wish to remain in bed all day in order to be relieved of all duties. 
 Others again, in spite of their internal conflicts, are able to so 
 comport themselves before the public as to avoid notice. When 
 
 'Zeitschrift fiir praktische Aerzte, 7, 1898, p. 6.
 
 200 CYCLOTHYMIA 
 
 such begin to express their troubles they are usually regarded by 
 those about them as imaginary. This judgment is all the more 
 often made by the laity, especially when some symptoms of excite- 
 ment are interspersed with the depressed ones. One symptom in 
 particular is noticeable by reason of its contrast with the patient's 
 complaints of apathy and indiflference ; this is a very striking 
 tendency to and capacity for criticism. The patients see every- 
 thing and feel a thousand little things as inconvenient and dis- 
 turbing quite in contrast to the true melancholic. They complain 
 of incompleteness in the arrangement of the rooms, complain of 
 the food, of the service, often not without foundation, but quite 
 in contradiction to their expressed state of indiflference to the 
 world at large. 
 
 Hecker further states that it is extremely common for these 
 patients to occpy their minds with suicidal ideas, and that fre- 
 quent talking about it seems to afiford some relief. The whole 
 condition is often likened by the patient to a machine whose oil 
 is dried up, while in the contrasting state the patients speak of 
 the machine as too well lubricated. 
 
 This latter state, which Hecker says Kraepelin terms "hypo- 
 mania," and Schiile " mania mitis," or " mania mitissima," which 
 he observes are to be considered as more fully developed forms, 
 shows a marked contrast with the former state. The patients 
 feel themselves the sense of well being, they are wittier, cleverer 
 and more capable than on healthy days. The tendency to fault 
 finding, which, as has been seen, is present in the depressed phase, 
 is strikingly amplified or modified. These patients often have a 
 very scornful, mocking attitude, and the internal unrest leads to 
 more or less exaggerated activity. Not only can these patients 
 stand more continuous work than on their well days, but not 
 infrequently is the character of the work a great deal better. 
 Often those of minor musical talent rise to heights rarely reached, 
 and in matters of artistic merit others reach a higher level than 
 ever. Some show a skill in literary production rarely equalled in 
 their normal phases. The biography of the " Mind that Found 
 Itself" is an evidence of this cyclothymic activity after a re- 
 covered cycle of a marked depression and manic cycle in an acute 
 psychotic outbreak. 
 
 Life is seen now only on its rosy side. The desire to help every-
 
 CYCLOTHYMIA 20I 
 
 body and interest themselves in everything is manifest through- 
 out. Much philanthropic overactivity and many reform propa- 
 ganda receive their greatest stimuli from minds in this hypomanic 
 stage. 
 
 Hecker relates an instance of multiple marriage engagements 
 made in the euphoric state and broken in the depressive phase in 
 a patient with cyclothymia. 
 
 In the mild stages, patients with cyclothymia are regarded as 
 normal. So soon, however, as the disorder develops a little more, 
 as it is apt to do in some, if not all, of its attacks, a series of more 
 striking symptoms arise. There is a great tendency on the part 
 of the patients to be extravagant and careless in their purchases, 
 a tendency to run about and to peculiar actions which the patients 
 themselves reason about with keen relish, an abnormal sense of 
 the ego, the wish to push oneself forward constantly, an exagger- 
 ated desire to bedeck oneself with badges or other evidences of 
 accomplishment, medals, ribbons, buttons, etc. Hecker notes that 
 not infrequently patients in this state have been mistaken for 
 paretics, a mistake which the writer has had occasion to observe 
 three times in the past six months. 
 
 In certain patients, Hecker writes, one finds the abnormal devel- 
 opment of lying and drinking tendencies and the desire to frequent 
 resorts of a questionable character. 
 
 Symptoms 
 
 I do not purpose to discuss the symptoms of the more frank 
 manic depressive psychosis, but wish to call attention to some of 
 the signs, at times slight in themselves, at times appearing isolated 
 — again in combination, which are indicative of the manic-depres- 
 sive make up, and of the milder types of this psychosis, to which 
 we have thought to give the name cyclothymia originally proposed 
 by Kahlbaum. 
 
 As to the former, the signs of cyclothymic constitution, there is 
 much to learn. Our casuistic contributions as yet are meager, and 
 offer only tentative and suggestive material, rather than funda- 
 mentals which admit of no controversy. As I purpose to take this 
 matter up in a separate communication I shall omit its further 
 consideration at this time.
 
 202 CYCLOTHYMIA 
 
 In the definite depressive phase of the manic-depressive psy- 
 chosis, it is well known that complaints of physical ailments are 
 extremely common and persistent, but the mental picture is so 
 apparent that the foundation for the belief in the physical illness 
 is recognized at its true value, and rightly dismissed from the 
 foreground in the therapeutic attack. This, however, is not the 
 case with the cyclothymic. Here every efifort is made to conceal 
 the mental disturbance, to minimize it, and as a corollary one 
 finds a corresponding enhancing of the complaints of physical 
 distress. The depressed cyclothymic hides his mental trouble 
 because he has insight, and does not desire to be considered men- 
 tally ill, and thus pushes the physical into the foreground, per- 
 haps himself believing it to be the source of his depression of 
 spirits. 
 
 Such patients may be seen at any and at all times in the con- 
 sultation rooms of the gynecologist, the laryngologist, the oph- 
 thalmologist, the internist, and above all the gastro-enterologist. 
 These patients are not the false gynopaths, the false cardiopaths, 
 the false gastropaths, and enteropaths of Dejerine — at least many 
 of them are not — these make up still another category, but are 
 true cyclothymic cases in the depressed phase. They are treated 
 for weeks, or even months — get well — swell the statistics of 
 favorable action of this or that operation, this or that remedy, not 
 to mention the cofifers of the enthusiastic, but blind specialist, 
 and then go through another series of gynecological tinkering, of 
 nose and throat sprays, of refitting of glasses, of stomach wash- 
 ing and of intestinal medication. Some of these cyclothymics 
 never pass out of the mild class of attacks and their affection is 
 rarely recognized. With others, however, the onset of a more 
 severe manic or depressed attack affords the clue to the interpre- 
 tation of the whole process. 
 
 In a restricted sense every mental disorder is a disorder of the 
 entire organism since every organ of the body has a definite 
 cortical representation. In the cyclothymic this relation of the 
 brain to the somatic organs is strikingly illustrated and both vaso- 
 motor and secretory anomalies are almost constant accompani- 
 ments. The cessation of the menses, the diminution of the salivary' 
 and renal secretions, and disturbances of the intestinal canal are 
 among the most striking of these abnormalities, and not enough
 
 CYCLOTHYMIA 2O3 
 
 weight has been put especially upon the latter. I can take up 
 only a few of these types in the restricted time at my disposal. 
 
 Gastro-enterological Types. — In the vast majority of cyclo- 
 thymic attacks in the depressed phase, there are present very 
 definite and tangible disturbances of the gastro-intestinal tract. 
 The so-called nervous dyspepsias are in great part cyclothymic, 
 and it behooves our gastro-enterologists to recognize such forms 
 and desist from useless therapeutic attempts. Kahn has likened 
 these attacks to a prodromal aura. There are many classical 
 illustrations in Raymond and Janets' works, where these cases 
 are described under the diagnosis of obsessions, neurasthenias and 
 psychasthenias. 
 
 These cyclothymic digestive disorders are not stereotyped. 
 Constipation is usual, and some slight dulness of mind, with per- 
 sistent dull headaches and frequently restlessness and sleepless- 
 ness, although sleep disturbances seem more pronounced in those 
 attacks which show a slightly manic tinge. In the depressive 
 attacks which usually pass under the head of nervous dyspepsia^ 
 — neurasthenia and the like, the mood is usually plaintive or dis- 
 tinctly cast down. Effort is largely automatic, and lacks spon- 
 taneity. The sense of being driven to do one's work is marked, 
 although a fairly high degree of efficiency may be present. Only 
 the necessary things are attended to, and some of these neglected. 
 
 The receptivity is much diminished. Emotional indifference 
 is frequent. These patients recognize their laziness, and often 
 take refuge behind sententious philosophy — " that life is hardly 
 worth the candle " — " God is unjust " — but they rarely weep, nor 
 show any marked anxiety, although timidity may be present. 
 
 These mental symptoms they try to hide and instead speak of 
 their continued loss of appetite, their diminishing weight, the 
 bitter taste in the mouth, the acid eructations. They feel pres- 
 sure in the body, a sense of stiffness and occasionally have pro- 
 fuse diarrheal discharge following marked obstipation. They 
 have marked anxiety and believe that they are suffering from 
 ulcer of the stomach, or that carcinoma is present. Careful and 
 tactful suggestion often reduces the anxiety, and relieves the 
 patient for a time, but the symptoms show a marked tendency to 
 
 * Dreyfus : Die nervose Dyspepsie, 1908.
 
 204 CYCLOTHYMIA 
 
 remission in spite of negative organic findings with the possible 
 exception of a markedly reduced motility, which is a result of the 
 mental depression. 
 
 Flemming, Schroder van der Kalk, Greisinger, Kraft-Ebing, 
 Schiile, Alt, and most of the older psychiatrists, regarded the 
 stomach disturbances as primary in just this sort of case, whereas 
 it seems now with the clear definition of manic-depressive insan- 
 ity before us that the very opposite is the real situation. These 
 patients get well not because of the local applications or the local 
 therapy, but because the cycle has run its course or that proper 
 mental therapeutics has been applied. Some of the most striking 
 cures — so-called — are seen in disciples of osteopathy, and kindred 
 sects. 
 
 Dipsomaniacal Types. — The cyclothymic constitution and mild 
 attacks of cyclothymia manifest themselves very frequently under 
 the guise of periodic alcoholic debauches. In the former case the 
 alcoholic excesses are apt to be fairly short in duration, and are 
 often interspersed with periods of productive energy, often in the 
 gifted of a very high order of efficiency. In the more pronounced 
 cyclothymic attacks the debauches have a tendency to be much 
 more prolonged, but as has already been intimated, hard and fast 
 lines are not to be drawn between the attacks which may be re- 
 garded as purely evidences of the cyclothymic constitution or 
 those of a more frank outbreak of a definite psychosis. 
 
 Illustrative types of this form of so-called dipsomania are not 
 difficult to find. They are frequent in the general practitioner's 
 work, although their relationship to a well defined psychosis in 
 a minor type are overlooked, precisely as walking typhoids may 
 be disregarded. Asylum studies are usually silent regarding this 
 type of case. General literature and history abounds in refer- 
 ences to this type of phenomenon, the best illustration of which 
 perhaps is afforded in the life of Alfred de Musset, as told by his 
 brother, Paul de Musset. " At times^** at the bottom of an armoire 
 he had an old yellow box coat, with six mufflers, and which could 
 be wrapped about him three times. Thus muffled up, he would lie 
 down on the floor (tapis) of his room and hum in a lamentable 
 
 " Paul de Musset. Bibliographie d' A. de Musset. Charpentier, 1879, 
 p. 91.
 
 CYCLOTHYMIA 
 
 205 
 
 tone some old contemporaneous air. Then in the evening he 
 would cast aside these rags and put on his best clothes. This 
 change of decoration was sufficient to turn the course of his ideas ; 
 he would leave to make a tour of the cafes of Paris where the 
 pleasures of the world made him forget the reverse of fate. 
 
 Soon he would be in a fever of excitement. . . . One spring 
 evening, says Paul de Musset, on returning from a walk, Alfred 
 recited to me the two first couplets of a dialogue between the 
 muse and the poet (La nuit de Mai) which he had just composed 
 under the horse chestnuts of the Tulieries. 
 
 He worked without interruption until the morning when he 
 appeared at breakfast. I did not notice any signs of fatigue on 
 his face. He had as his Fantasio the month of May. The muse 
 possessed him. During the day he would take the lead in con- 
 versation, and work like a chess player who plays two games at 
 one time. At times he would leave us to write a dozen verses, 
 and then would return to chat with us. But at night he returned 
 to work as he would to a lover's rendezvous. He had late supper 
 served him in his room. He purposely asked for two services, in 
 order that the muse should have her place designated. 
 
 All of the lights were lit. He lit twelve candles. People of 
 the house seeing this illumination would think he was giving a 
 ball. On the morning of the second day, the piece having been 
 accomplished, the muse took herself away, but she had been so 
 well received, that she promised to return. The poet blew out his 
 candles, went to bed and slept until evening. On awakening he 
 reread the verses, and could find nothing to retouch. 
 
 After the inspiration — daughter it may be of excitation — here 
 is the other stage. Then from the ideal world in which he had 
 lived for two days, the man fell brusquely to earth, sighing as if 
 one had awakened him from a delicious and fairy-like dream. 
 
 After the enthusiasm there followed all at once an ennui, a dis- 
 taste for ordinary life, and from its petty miseries, a deep melan- 
 choly. In order to relieve himself from such a depression, it 
 seemed that all the luxury of Sardanapolis, all that Paris could 
 offer of distractions and of refinements could hardly suffice." 
 
 And then Paul de Musset adds — "in the eyes of most people
 
 206 CYCLOTHYMIA 
 
 these alternations of over-excitement, and of depression are only- 
 weaknesses, this is an error. "^^ 
 
 Georges Sand^^ has given us new testimony of these crises of 
 moods (humeur). 
 
 " They were together in Italy, he wished to work, but suddenly 
 he felt himself struck with a momentary loss of power, and fell 
 into one of those cases of spleen against which he did not know 
 how to react alone. He would be overcome by emotions coming 
 from without ; magnificant music came from the ceiling ; an 
 Arabian horse would come in through the key hole. It made no 
 difference what delicious and terrible occurrence which would 
 tear him from himself and under the impulsion of which he felt 
 exalted and renewed. But here is the other period. 
 
 The days following he did not come home at all at night — he 
 went out he said — in a boat and exercised himself rowing and 
 taking lessons from a local fisherman. He pretended to find that 
 the fatigue, which lessened the excitation of his nerves, was good 
 for the work of the afternoon. But this excitation did not con- 
 strain him to spend the entire night in the boat of some fisherman. 
 And then Georges Sand makes the sorrowful disclosure of the 
 dipsomania of de Musset. 
 
 " Has he not said to me, and alas, almost proved it, that I 
 smothered his genius in wishing to destroy his fever. When I 
 believed him to have come to the limit of disgust in his excesses, 
 have I not seen that he was anxious for more? When I have 
 said to him return to the world, he feared my jealousy, and threw 
 himself into gross and mysterious debaucheries. He would come 
 home drunk, with his clothes torn and his face bleeding." 
 
 Is it not a matter for reflection to learn that the same morbid 
 symptom may show itself under the aspect of a night of orgy, or 
 of a night of sublime inspiration, says Kahn. 
 
 It is, I believe, recognized by many at the present time that 
 dipsomania — or periodic drunkenness — is not by any means al- 
 ways an epileptic equivalent. Such is by far too narrow an in- 
 terpretation, and, in fact, I am inclined to regard periodic drunk- 
 enness occurring as an epileptic equivalent to be extremely un- 
 common. That such cases do occur is unquestioned, and they are 
 
 " L. c, 145 and following. 
 " EUe et lui, p. 56, Levy.
 
 CYCLOTHYMIA 20/ 
 
 not frequent, but on the other hand, periodic drunkenness is a 
 common cyclothymic manifestation, as well as a frequent compli- 
 cation in a fully developed manic-depressive psychosis. I have 
 observed it both in the cyclothymic depressed, and in the cyclo- 
 thymic excited periods — though rarely in the same individual. Its 
 occurrence in some cyclothymic mixed states has been commented 
 on by Dupre," and such an interpretation has seemed to me justi- 
 fiable in a few cases under personal observation. 
 
 My own experience has been too limited to offer any figures as 
 to the tendencies, but I have seemed to encounter considerable 
 quiet drinking which has brought many a patient to the verge of 
 an alcoholic neuritis, and even a Korsakow syndrome in the de- 
 pressed cyclothymics, whereas the more boisterous and active de- 
 bauches are found among the hypomanics. 
 
 Sexual Types. — Closely allied with the subject of periodic 
 drinking, and often, though not always, accompanying it, the sub- 
 ject of periodic sexual erethism and sexual frigidity asserts itself. 
 
 The acute mental disturbances of young brides, and the periodic 
 apparent hypomanic disorder found in fiances are not here referred 
 to, Romfeld^* and Dost^^ have discussed these questions fully, but 
 I refer to shorter or longer manifestations of abnormal sexual 
 excitement and of sexual frigidity which are the expressions in 
 the sexual sphere of cyclothymic attacks. 
 
 It is far from uncommon to learn that the loss of chastity and 
 conception has resulted to a young woman whose self-control 
 was reduced by reason of her mental disorder, mild though it may 
 have been. Such a distressing complication of a cyclothymia 
 occurs in some of the " best families." Again hasty, and some- 
 times ill-considered marriages have been permitted because of ex- 
 cessive sexual excitement in some young woman which excess has 
 been the expression not of a balanced ardent nature, but of a patho- 
 logical state, with all the ear marks — for one who can read the 
 little things — of a cyclothymia. Such marriages continue to 
 supply their later stock of those not only with a cyclothymic con- 
 stitution, but with children who develop a well-marked manic- 
 
 " Ballet, Soc. de Neur. de Paris, July 5, 1900; March 7, 1907. Soc. de 
 Psychiatric de Paris, March 30, 1903. 
 "Zyclothymie bei Brauten. Med. 
 "Allge. Zeits. f. Psych., 54, 1902.
 
 208 CYCLOTHYMIA 
 
 depressive psychosis. Illustrative cases can be supplied by prac- 
 tically all the members of this association. 
 
 With this short introduction to the general topic of the mild 
 types of manic-depressive psychosis, or cyclothymias, I leave the 
 subject for your consideration.
 
 LIST OF PAPERS READ BEFORE THE NEW YORK 
 PSYCHIATRICAL SOCIETY 
 
 April I, 1903. 
 
 Discussion : " Infantile Insanity in its Relation to Moral Perversion 
 and Crime." 
 May 20, 1903. 
 
 Discussion : " On the Classification of Mental Diseases." 
 November 4, 1903. 
 
 No paper. 
 January 6, 1904. 
 
 Paper: "Plans for Psychopathic Wards and Hospitals." Dr. Clark. 
 March 2, 1904. 
 
 Discussion : " Report of the Committee on Classification of Mental 
 Diseases." 
 May 4, 1904. 
 
 Paper : " Fright as the Cause of Mental Disturbances." Dr. Bailey. 
 November 2, 1904. 
 
 Paper : " Curability of General Paresis." Dr. Dana. 
 January 3, 1905. 
 
 Paper : " Habit Disorganization in Essential Deteriorations." Dr. 
 Meyer. 
 March i, 1905. 
 
 Paper : " Mental and Nervous Diseases in Classic and Pictorial Art." 
 Dr. Clark. 
 
 Paper: "Art Among the Insane and Degenerate." Dr. Dana. 
 May 3, 1905. 
 
 Paper: "The Mechanisms of the Phenomena of Psychopathology." 
 Dr. Hirsch. 
 October 4, 1905. 
 
 Paper: "Drug Deliria." Dr. Hoch. 
 December 6, 1905. 
 
 Paper : " Insanity as a Result of Hysterectomy and Oophrorectomy." 
 Dr. Hammond. 
 January 6, 1906. 
 
 Paper : " People vs. Wood." Dr. Bailey. 
 March 7, 1906. 
 
 Paper: "People vs. Young." Dr. Hirsch. 
 May 2, 1906. 
 
 Paper: "Plans and Policy for the Work of the Coming Winter." Dr. 
 Meyer. 
 November 7, 1906. 
 
 Paper: "Diagnostic Criteria of General Paresis." Dr. Campbell. 
 
 15 209
 
 2IO LIST OF PAPERS READ 
 
 January 2, 1907. 
 
 Paper: "The Prognostic-symptomatic Complex of Manic-depressive 
 Psychosis." Dr. Kirby. 
 March 4, 1907. 
 
 Paper : " Psychogenetic Factors in some Paranoic States." Dr. Hoch 
 May I, 1907. 
 
 Paper : " Recommendations Concerning the Improvement of Medico- 
 legal methods." Dr. Bailey. 
 November 6, 1907. 
 
 Paper : " Ocular Disc changes in Dementia Prsecox." Drs. Clark and 
 Tyson. 
 
 Paper: "Anxiety Psychoses." Dr. Kirby. 
 January 8, 1908. 
 
 Paper : " Psychogenesis and Dementia Prsecox." Dr. Hoch. 
 March 4, 1908. 
 
 Paper : " The Relation of Hysteria and Psychasthenia to Dementia 
 Praecox." Dr. Meyer. 
 May 6, 1908. 
 
 Paper : " On the Voluntary Admission to State and Private Institu- 
 tions." Dr. Brooks. 
 November 4, 1908. 
 
 Paper : " A Study of the Mental make-up in different Functional 
 Psychoses." Dr. Hoch. 
 January 6, 1909. 
 
 Paper : " Etiological Factors of the Psychoses." Dr. Mabon. 
 
 Paper: "Racial Psychopathology." Dr. Kirby. 
 
 Paper : " Ocular Reactions among the Insane." Dr. Diefendorf . 
 March 3, 1909. 
 
 Paper: "Multiple Melancholia." Dr. Dana. 
 
 Paper : " A Comparative Study of the Capacity for Mental work in 
 Dementia Praecox and Alcoholic Insanity." Dr. Cotton. 
 May 5, 1909. 
 
 Paper: "Clinical Forms of Periodic Drinking." Dr. Bailey. 
 
 Paper: "Contribution to the Etiology of Manic-depressive Insanity." 
 Dr. Hoch. 
 November 3, 1909. 
 
 Paper: "Further Report on Cases of Alleged Cured Pre-paresis." Dr. 
 Dana. 
 
 Paper : " On some Ethical questions in Psychiatrical Expert Work." 
 Dr. Hirsch. 
 January 5, 1910. 
 
 Paper : " The Alleged Increase of Insanity." Dr. Stedman. 
 March 2, 1910. 
 
 Paper : " The Content and Form of the Psychosis or Psychoanalysis 
 in Psychiatry." Dr. Campbell. 
 
 Paper: "The State Care of the Dangerorsly Insane." Dr. Hammond. 
 April 27, 1 910.
 
 LIST OF PAPERS READ 2 I I 
 
 Paper : " A Case of Malingery." Dr. Cotton. 
 November 2, 1910. 
 
 Paper: "The Insane in Japan." Dr. Peterson. 
 
 Paper : " Cyclothymia, — the Mild Forms of Manic-depressive Psy- 
 chosis." Dr. Jelliffe.
 
 THE EYE SYNDROME OF DEMENTIA PRECOX 
 
 Ocular Signs and Symptoms of Dementia Precox and their 
 Significance, as Observed in 115 Consecutive Cases^ 
 
 By H. H. Tyson, M.D. 
 surgeon, n. y. ophthalmic and aural institute, new york city 
 
 AND 
 
 L. Pierce Clark, M.D. 
 
 SENIOR ATTENDING PHYSICIAN, HOSPITAL FOR NERVOUS DISEASES, OF 
 NEW YORK CITY, NEW YORK 
 
 In 1899, Seglas saw a case of anxious melancholia, followed 
 by mental confusion, evolve parallel with gastro-intestinal auto- 
 intoxication. Meyer reported five similar cases. The idea that 
 dementia prsecox is an autotoxic disease originated with Morro, 
 who first connected hebephrenia with this cause in 1900. The 
 evidence for its autotoxic nature may be grouped as follows : 
 (i) There is a coincidence of certain ocular symptoms with gas- 
 trointestinal autointoxication similar, in many aspects, to those 
 seen in typhoid, lead colic, and simple intestinal putrefaction. 
 (2) The urine in dementia praecox shows very defective elimina- 
 tion. (3) Fully one-half of the subjects of dementia praecox 
 die of tuberculosis. (4) The co-existence of certain toxic derma- 
 toses, such as certain types of erythema, vasomotor paresis, with 
 chronic gastrointestinal intoxication, is noteworthy. (5) Some 
 additional facts are at hand, as shown in the co-existence of 
 psychic excesses, neurasthenia, etc., with states of autointoxica- 
 tion. (6) The study of the blood in dementia praecox shows 
 evidence of a toxic state. 
 
 'This work was undertaken at the suggestion of Dr. Clark and the 
 greater part of the work was carried out in his service at the Manhattan 
 State Hospital and at the Vanderbilt Clinic (Dr. Starr's service). Dr. 
 Tyson made the eye examinations and is responsible for the detailed find- 
 ings of the same. Both authors are jointly responsible for the interpreta- 
 tive significance of the study. 
 
 212
 
 THE EYE SYNDROME OF DEMENTIA PR.ECOX 2I3 
 
 More specific evidence is at hand in Kuhnt and in Blin's work, 
 especially the latter. In 1905 Blin published a monographic con- 
 sideration of the autotoxic nature of dementia prascox. He at- 
 tempted to show that the retinal changes are analogous to those 
 seen in various acute and chronic infections. It is of passing his- 
 toric interest to say that Dide and Assicot (1901) had already 
 noted the alteration of anemia and congestion in the discs of 
 dementia praecox. None of these various observers have made 
 any thorough or systematic attempt to analyze the significance of 
 the eye changes in dementia praecox. 
 
 The subject of the ophthalmoscopic changes in dementia prae- 
 cox receives little attention in the most recent reference works. 
 Our bibliographic research has unearthed but two studies in which 
 the subject is considered. These are the general papers by Kuhnt 
 and Wochenin on alterations in the retina in psychoses, and the 
 work by Blin on the ocular changes in dementia praecox. Kuhnt 
 and Wochenin- examined 511 cases of mental diseases with the 
 ophthalmoscope. Of these there were 5 cases of hebephrenia. 
 The other forms of dementia praecox arc not mentioned. Patho- 
 logic changes in but one case are mentioned, presumably the 
 others were not noteworthy. This one patient had pallor or 
 anemia of the temporal half of the papilla. 
 
 The work of BHn is much more to the point. He examined 
 the retina in 87 cases of dementia praecox. A second examination 
 was frequently undertaken. Despite his extensive material, Blin 
 appears to have made no careful analysis of the significance of 
 the findings. Of the 87 cases, some abnormality of the papillae 
 was found in 59. The material was divided into three groups. 
 Nine cases (10.2 per cent.) showed constant hyperemia of the 
 discs, and in 23 (36.8 per cent.) the congestion was transitory. 
 Blin does not mention the condition of the blood vessels as to 
 overfilling, tortuosity, etc., nor does he appear to have examined 
 closely into the coincident eye symptoms necessary to establish an 
 eye syndrome for dementia praecox. An anemia of the papillae 
 was constant in 7 cases (8 per cent.), and inconstant in 15 (25.3 
 per cent.). He uses the term intermittent in connection with the 
 
 'Ueber Veriinderungen der Netzhaut bei Geisteskrankheiten, Ztschr. 
 f. Augenh., 1903, xiii, 89.
 
 214 "^^^ ^^^ SYNDROME OF DEMENTIA PRECOX 
 
 latter. There were 5 cases in which congestion alternated with 
 anemia (5.74 per cent.). 
 
 Various points often mentioned in individual cases are not 
 summed up, such as haziness of the border, or the absence of 
 demarcation between papillae and retina, predominance of lesion 
 in one eye, and the like. Doubtless all these facts seemed some- 
 what contradictory and did not lend themselves easily to a 
 summary. 
 
 Three years ago we undertook an independent research on 
 the significance of the ocular signs and symptoms in dementia 
 praecox. We have analyzed 115 consecutive cases. The work 
 was undertaken with the view that a careful analysis of the eye 
 symptoms in dementia praecox might throw some definite light on 
 the uncertain and perplexing pathogenesis of the disorder. In 
 this respect, we believe we have not been disappointed, inasmuch 
 as we have found definite changes and symptoms in all cases which 
 are fully distinctive of this psychosis. 
 
 The fundus changes as seen clinically may be divided into 
 three groups, which are usually in the order of their occurrence, 
 as follows: 
 
 1. Congestion of discs; hyperemia and edema; dilated, dark 
 colored veins; slightly contracted arteries and blurring of the 
 edges of the discs, all varying in degree. These changes consti- 
 tute a low grade of perineuritis of the optic nerve. 
 
 2. Congestion of the nasal side, with temporal pallor of discs, 
 dilated veins, contracted arteries. 
 
 3. Pallor of discs, dilated veins, contracted arteries. These 
 changes constitute anemia and partial atrophy of the optic nerve. 
 
 One hundred and nine cases were examined with the ophthal- 
 moscope; 55 were males and 54 females. The ages of the males 
 were from 12 to 47 years, and those of the females were from 13 
 to 39 years. 
 
 All the different forms of dementia praecox were under study. 
 While the results by form types have not been fully analyzed, we 
 are prepared to say that the more marked changes in the eye syn- 
 drome were found in the more rapidly deteriorating types of 
 dementia praecox. 
 
 The cases embrace those who have used alcohol and tobacco 
 moderately or to excess, as well as abstainers. It is possible that
 
 THE EYE SYNDROME OF DEMENTIA PILECOX 21 5 
 
 alcohol and tobacco have contributed toward the clinical picture 
 in some cases. In differentiating the pathologic condition of the 
 optic nerve in tobacco and alcohol users from those in cases of 
 dementia prsecox, one observes central scotoma in the former. 
 The one case showing a central scotoma for red in dementia prae- 
 cox gave a history of alcohol and tobacco excesses. The disc 
 changes in dementia praecox have some resemblance to those seen 
 in the toxic amblyopia of tobacco and alcohol. But the fundus 
 changes above detailed are seen in all cases under study. There 
 is strong evidence that some other potent toxin is responsible for 
 the disc changes in dementia praecox. We do not hesitate to say 
 that we believe the toxin is primarily a vascular poison. Its most 
 probable source is in the autointoxication (intestinal putrefaction 
 is almost invariably evident from clinical symptoms) from the 
 intestines or from the liver. It is possible that a faulty metab- 
 olism from a perverted action of some of the ductless glands 
 (thyroid especially) may be the pathogenic agent. The primary 
 departure from the normal in the disc is in the veins. They 
 become dilated, tortuous and darker than normal. Edema of the 
 disc appears shortly afterward. These changes are analogous to 
 those seen in the passive congestion of the face and hands in 
 dementia praecox cases. All these edemas produce such lasting 
 disturbance in the nutrition of the optic nerve that slow degenera- 
 tion of the nerve fibers finally results. Thus, of the 109 cases 
 examined by the ophthalmoscope a low grade perineuritis was 
 found 62 times in the right eye and 67 times in the left. Temporal 
 pallor, with nasal side congested, was found in the right eye 10 
 times, in the left eye 11 times. Pallor of discs was found in the 
 right eye in 37 cases and in the left eye in 31 cases. 
 
 Inasmuch as the disc changes in the first stages resemble some- 
 what those seen in ordinary intestinal toxemia, we have repeatedly 
 examined the discs in a number of cases while the patients were 
 under active hygienic treatment of free catharsis, intestinal anti- 
 septics, baths and dietetic regulations. A marked degree of bet- 
 terment was noticed of the congestive margins of the discs, but 
 the central edema and transitional pallor have continued. Indeed, 
 while patients were under this treatment a general physical im- 
 provement was noticed but the mental state seemed little im- 
 proved.
 
 2l6 THE EYE SYNDROME OF DEMENTIA PRECOX 
 
 Coincident with the study of the changes in the papillae, the 
 pupils were examined in 85 cases. The changes uniformly found 
 here were not less significant. The examinations were made in 
 moderately light rooms with the eyes fixing a distant object. The 
 size of the pupils varied from 3^ mm. to 7 mm., with an average 
 of 4'^%5 mm., while the average of the control pupils (physician 
 and attendants) was 3^%5. An average enlargement of i%5 mm. 
 for dementia praecox over the normal was evident. 
 
 The light reaction was normal in 71 cases and sluggish in 14. 
 Consensual reaction was active in 68 cases and sluggish in 17 
 cases. 
 
 Accommodation and convergence were active in 71 cases and 
 sluggish in 13. Hippus was present in one case. 
 
 The sensory pupillary reflex was slightly positive in 6 cases 
 and negative in 79 instances. The psychic reflex was sHghtly 
 positive in 4 cases and negative in 85 cases. Piltz-Westphal reflex 
 was positive in 2^ and negative in 85 cases. 
 
 Great care was exercised in measuring the pupils on account 
 of the tendency of the eyes to change their visual lines. One is 
 apt to complicate the accommodation and convergence reflex with 
 the other tests. The negative reactions of the pupil appear to be 
 due ( I ) to loss or partial loss of function through defective nerve 
 innervation; (2) defect in attention ; (3) diminished apperception. 
 
 Corneal sensibility was diminished in 69 cases and normal in 17. 
 
 The visual color fields were examined in 81 cases. All were 
 found concentrically contracted. The largest field was 30 degrees, 
 the smallest o degrees. The fields were practically abolished. 
 The average of the 81 cases was 10.6 degrees, which was a marked 
 contraction from the normal. This may be explained partially by 
 the inattention of those patients, diminished capacity for exter- 
 nalization and finally, and not least, by the edema and congestion 
 of the optic nerve (perineuritis) in the first stage of degeneration 
 of the nerve and by the ultimate shrinkage of the new connective 
 tissue in the partial atrophy of the nerve. 
 
 The changes in the discs, pupils, visual fields and corneal sen- 
 sibility which, when taken together, constitute the new syndrome, 
 are all in accord with each other. In our examination of all other 
 types of insanity, imbecility or idiocy we have found no other 
 
 ' At first positive, later examination was negative.
 
 Fig. I. A. B., "DP." 26 years old, two 
 years in Manhattan State Hospital. Wards 
 Island. Left eye shows congestion and 
 edema of entire disc, edges blurred and 
 indistinct, filling in of physiological exca- 
 vation. Veins dilated, dark and tortuous; 
 relative size compared to arteries, 2I to i. 
 (Direct method of examination.) 
 
 Fig. 2. K. M., "DP," in Manhattan 
 State Hospital for 13 months. Quite de- 
 teriorated. Right eye shows temporal pallor, 
 with nasal congestion and edema, blurring 
 of edges on the nasal side. Veins dark and 
 tortuous, dilated ; relative size of veins to 
 arteries, 2 to i. (Direct method of exami- 
 nation.) 
 
 Fig. 3. M. E., " DP." Right eye. Shows 
 pallor of entire disc. Edges blurred and 
 indistinct. Veins dilated, dark and tortuous. 
 -Arteries slightly contracted. Relative size, 
 compared to arteries, 2 to i. (Direct 
 method of examination.)
 
 THE EYE SYNDROME OF DEMENTIA PRECOX 21/ 
 
 condition similar to what we have outHned here for dementia 
 prascox. 
 
 The dinical significance of these findings is of importance: 
 
 1. They indicate that dementia praecox is attended by such 
 an early and constant syndrome of alteration and disc, visual field, 
 pupil and corneal sensibility as to materially aid in diagnosticating 
 this psychosis. Consideration of the syndrome will particularly 
 aid in the diflferential diagnosis of dementia praecox from the 
 manic-depressive group, acquired neurasthenia, hysteria and the 
 various forms of imbecility and constitutional inferiority. 
 
 2. The syndrome is a distinct contribution to the theory that 
 dementia praecox is an autotoxic disease, and that the poison is 
 primarily vascular, which finally induces neuronic degeneration. 
 It points to a toxin of some sort, which is either a metabolic defect 
 in the tissues (ductless gland defect) or, what seems more prob- 
 able, that the poison is generated in the liver or in the gastro- 
 intestinal tract itself. 
 
 3. The syndrome is of prognostic value, as the severer grades 
 of eye changes are found in the more rapidly deteriorating cases. 
 
 4. Finally, the optic nerve lesion is quite in accord with our 
 best knowledge of the pathologic anatomy of dementia praecox, in 
 other tracts of the brain (than the optic nerve which itself may 
 be counted an analogue). The early vascular changes in the brain 
 ought to receive more serious investigation. 
 
 We desire to thank Dr. Mabon and his staflF, Dr. Smith of 
 Central Islip and his staflf, and the staff of assistants in the neuro- 
 logic department of the Vanderbilt Clinic (Dr. Starr's service) 
 and Dr. C. E. Atwood in particular, for the courtesies extended 
 to us in placing their patients at our command. 
 
 Since the publication of our original paper upon the eye syn- 
 drome of dementia prascox no similar carefully recorded observa- 
 tions upon the subject have been made. It is true, however, that 
 the fundamental postulate of the cause of the syndrome, namely, 
 the toxic character of the mental disorder, has been under con- 
 tinuous study. The rival camps of a psychic or somatic origin 
 for the disease have been in a constant state of warfare. The 
 attitude of the Kraepelinian school of somatists and the Meyer- 
 Hoch school of psychogenists are too well known for us to detail 
 the special viewpoints of each here. It is hoped a mutually sup-
 
 2l8 THE EYE SYNDROME OF DEMENTIA PRECOX 
 
 portive middle ground may succeed the present day partisanship. 
 
 The main contention of our paper is that a fairly constant eye 
 syndrome exists in dementia praecox, and secondly the best hypoth- 
 esis for explaining the presence of the same is upon some endog- 
 enous or exogenous toxic substance. We believe the first posi- 
 tion has been established. From the partial and incomplete nature 
 of our study the second contention can only be urged as a con- 
 tributing study to that end. 
 
 It is unnecessary to point out the remarkably low resistance 
 of nerve^issue to toxins in dementia prsecox. As is well known 
 in ophthalmic practice, degenerative changes in the nerve head 
 from toxins are at first transitory, requiring time for producing 
 distinct pathological changes as shown exquisitely in tobacco ambly- 
 opia. Even then such fundus changes are apparently slight and 
 not recognizable microscopically but should be by more delicate 
 methods of analysis. The extra vulnerability of nervous tissue in 
 dementia praecox may be fairly well shown in a kindred state of 
 inherited vice of constitution, that of imbecility. In a study of 
 the eye in mental defectives by Clark and Cohen,* one of the 
 objects of the study was to note whether a parallelism in consti- 
 tutional defect, namely a strong tendency to neural degeneration, 
 existed in both disorders. It is interesting to note in this connec- 
 tion that the authors found fully three fourths of all cases of 
 idiocy of their study showed varying degrees of retrobulbar neuri- 
 tis of a degenerative character. However one may search for 
 exciting causes in the degeneration of the optic nerve in idiocy or 
 dementia prsecox, one needs to bear in mind that parallelism prob- 
 ably extends no further than an inherent tendency in both, for 
 the development and character of the changes in each are totally 
 unlike. Then, too, defectives never have the pupillary or other 
 signs of the eye syndrome of dementia praecox. 
 
 In examining the fundus of the eye, allowance must, of course, 
 be made for each individual variation within relatively wide 
 physiological limits. The difference in appearance of the fundi 
 in anemic individuals and well nourished ones is not inconsider- 
 able. The same relative disproportion in sizes of arteries and 
 
 * A Study of the Eye in Mental Defectives, Journal of American 
 Medical Association, April i6, igio, Vol. LIV, pp. 1287, 1288.
 
 THE EYE SYNDROME OF DEMENTIA PRECOX 219 
 
 veins exists in most all cases while the actual calibre of vessels 
 varies greatly. 
 
 As to the different stages of the fundus changes since study- 
 ing our cases over a longer period of observation, it is a question 
 with us whether our first and second stages should not be trans- 
 posed. As is well known and first pointed out by Horsley, in 
 choked disc from brain tumor, the earliest changes are found in 
 haziness of the superior nasal quadrant of disc. But as in the 
 examination of the early cases examined at the clinics (prehos- 
 pital or preasylum stage) we noted a majority of the congestive 
 stage, i. e., entire disc congested, etc., as originally described in 
 stage No. i. 
 
 Size of pupils : Those which were less than the normal average 
 were taken in bright light and were included so as to account for 
 and make a total average for all our cases examined, otherwise 
 if the average size of pupils were considered only of those that 
 had been measured in a moderately lighted room as the majority 
 had been, then the average size would have been a trifle larger 
 than reported. 
 
 Great care needs to be exercised in testing sensibility of cornea ; 
 one should not touch eyelashes, nor lids, nor have image of ap- 
 proaching objects or test fall on visual field. One should care- 
 fully approach the cornea from the periphery. Additional cases 
 making 200 in all have been examined and about the same per- 
 centage of changes have been found as were observed in the 115 
 first reported. 
 
 Examination of fundi of dementia prsecox cases by Dr. Hol- 
 den, subsequent to our examinations, changes were noted by him 
 in about fifty per cent, of cases ; but he did not study the syndrome 
 in its entirety. He confined himself entirely to examination of 
 fundi alone. 
 
 The recent, careful and rather exhaustive work of Southard 
 upon dementia praecox is worthy of more than passing notice. 
 Southard made a careful examination of 62, brains obtained from 
 dementia prsecox patients who died at the Danvers (Mass.) State 
 Hospital. In his investigations he laid particular stress on the 
 "topographic idea" which had occurred to him, when, some years 
 ago, he made an analysis of the first 1,250 necropsies of the
 
 220 THE EYE SYNDROME OF DEMENTIA PRECOX 
 
 Danvers State Hospital and collected the lesions of different parts 
 of the brain in card catalogue form. In a surprisingly large num- 
 ber of cases he found local areas of sclerosis, atrophy or aplasia. 
 His conclusions in regard to dementia prsecox are as follows : 
 
 " I. Existent evidence for the organic nature of dementia 
 praecox is not wholly convincing, since (a) the cytologic changes 
 described are found also in cases of toxic deliria and in cases 
 complicated by severe visceral disease, and (b) the stratigraphic 
 changes described are found also in senile cases without charac- 
 teristic symptoms of dementia prgecox. 
 
 2. Resort must, therefore, be had to the topographic idea, for 
 the adequate exploitation of which total-brain sections, with cyto- 
 logic exploration of all areas, are ideally necessary. 
 
 3. Random blocks of brain tissue with demonstration of satel- 
 litosis, infrastellate gliosis, or disintegration products of cell dis- 
 order will throw little light on the mechanism of dementia praecox. 
 
 4. The data of the functionalists (dissociation, sejunction, 
 intrapsychic ataxia, and the like) are of the utmost importance as 
 indicating the essential focality of the pathogenic process and 
 the focal variations in its severity. 
 
 5. The curability of certain cases, the remissive character of 
 some cases, the speedy disappearance of particular symptoms, the 
 persistent complexity of reaction in some instances, the absence 
 of characteristic severe projection-system symptoms, all indicate 
 that the process is histo-pathologically mild and that the focal 
 changes found will be found but slightly destructive or even irri- 
 tative (in the sense of slight injuries readily repaired or compen- 
 sated for). 
 
 6. Grossly destructive lesions of a transcortical character in 
 Wernicke's sense might conceivably effect, e. g., a permanent cata- 
 tonic complex and doubtless will be found to do so occasionally ; 
 but the protean and progressive character of dementia praecox will 
 exclude such transcortical injuries from playing a large part in 
 the pathogenesis. 
 
 7. The focal lesions to be sought for will doubtless escape 
 macroscopic notice in many instances, since the volume of appara- 
 tus engaged in affecting very prominent symptoms is often slight 
 and is spread very thin in numerous areas.
 
 THE EYE SYNDROME OF DEMENTIA PRECOX 221 
 
 8. Studies of the " soft brain " and of gliosis in epilepsy have 
 proved, however, that even comparatively slight degrees of cor- 
 tical gliosis can often be palpated at autopsy. 
 
 9. Palpable glioses of a focal or variable character combine in 
 numerous instances with visible atrophy and microgyria, have 
 been found in over half the series under examination, in cases 
 regarded as clinically above reproach, and not subject to coarse 
 wasting processes, focal encephalomalacia, cortical arterioscle- 
 rosis, or diffuse chronic pial changes. 
 
 10. The frequent co-existence of several foci of sclerosis or 
 atrophy in the same brain and the microscopic observation of 
 milder degrees of nerve-cell disorder and gliosis in regions with- 
 out gross lesions tend to the conception that the agent is more 
 general and diffuse in its action than would seem at first sight, so 
 that future research may well demonstrate that certain instances of 
 coarse brain wasting and even of diffuse chronic leptomeningitis 
 belong to the group (microscopic corroboration necessary for 
 assigning values to focal variations). 
 
 11. The microscopic examination of the residue of cases in 
 which gross lesions or anomalies were not described, shows the 
 same tendency to gliosis and satellitosis in numerous instances and 
 the same tendency to focal variations from gyrus to gyrus exhib- 
 ited by the gross lesion group. These findings suggest that the 
 minor gross lesions and anomalies of several cases actually 
 escaped notice (the protocols, though drawn up with a certain 
 system, are by various hands) at autopsy, so that the probable 
 actual proportion of gross lesions is 68 per cent. If microscopic 
 evidence is resorted to, the organic proportion in our series rises 
 to 86 per cent. 
 
 12. Several groups of cases were classified from the distribu- 
 tion of microscopic lesions, although the focal purity of these 
 cases can often be brought in question from the results of micro- 
 scopic examination (infrastellate gliosis and satellitosis also in 
 macroscopically normal areas). 
 
 I. Pre-Rolandic group, including a superior frontal-prefrontal 
 sub-group of paranoidal trend. 
 
 II. Post-Rolandic group, including (a) postcentral-superior 
 parietal (sensory perceptual) sub-group in which catatonic fea- 
 tures are the common factors; (b) occipital sub-group.
 
 222 THE EYE SYNDROME OF DEMENTIA PRECOX 
 
 III. Infra-Sylvian group (too small for clinical correlations). 
 
 IV. Cerebellar group (catatonic features). 
 
 13. If these data find general confirmation, they will doubtless 
 go far to unify discussion, since mild, variable and progressive 
 intracortical lesions, proceeding at different rates in different 
 parts of the apparatus, and having the peculiar distributions indi- 
 cated above would explain adequately some of the contentions of 
 the dissociationists, while remaining not wholly inconsistent with 
 Kraepelinian ideas. 
 
 14. The frontal-paranoid correlation is in line with modern 
 physiologic ideas, but it must be granted that the occipital and 
 temporal regions, as elaborating important long-distance impulses, 
 may well play a part also in paranoid states. 
 
 15. The cerebellar-catatonic correlation is doubtless in line 
 with some contentions of the Wernicke school, and obvious com- 
 ments might be made in connection with the proprioceptive func- 
 tions of the cerebellum (Sherrington). 
 
 16. The post-central-superior-parietal relations to catatonic 
 symptoms are perhaps theoretically the most novel suggestion 
 from the work, but here again the results are not consistent with 
 modern physiology. 
 
 17. The topographic study of dementia praecox brains, both 
 gross and microscopic, is commended as likely to shed new light 
 on the pathogenesis of certain symptoms, notably paranoidal and 
 catatonic symptoms." 
 
 These conclusions of Southard's are given at length not only 
 as they are undoubtedly the best summary of the " topographic 
 study " of the praecox brain at present hand, but because the 
 lesions of atrophy and sclerosis are suprisingly analogous for that 
 we note in the progressive degenerations in the nerve head itself. 
 Our work might therefore be properly called a clinical contribu- 
 tion to Southard's " topographical histo-pathological study."* 
 
 "Our special thanks are due to Dr. Brun for his faithful drawings, 
 in color, of the eye grounds in our cases. Drawings are a part of the orig- 
 inal contribution.
 
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