Source: Internet Archive scan of Thomas Johnstone 1904 translation Source URL: https://archive.org/details/lecturesonclinic00kraeuoft Translator: Thomas Johnstone (1904) Public domain basis: Public-domain 1904 English translation.l^*^ KS3.ll '^thrarg of llie tEoniiittT I 9^4- LECTURES ON CLINICAL PSYCHIATRY LECTURES ON CLINICAL PSYCHIATRY BY DR. EMIL KRAEPELIN ^l?5(b-ie)^b. PROFESSOR OF PSYCHIATRY IN THE UNIVERSITY OF MUNICH ButboriscD ^translation from tbe Second ©erman EDition REVISED AND EDITED BY THOMAS JOHNSTONE M.D. Edin., M.R.C.P. Lond. MEMBER OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN AND IRELAND ; FELLOW OF THE ROYAL MEDICAL SOCIETY ; FELLOW OF THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH, AND MEMBER OF THE LEEDS AND WEST RIDING MEDICO CHIRURGICAL SOCIETY THIRD ENGLISH EDITION NEW YORK WILLIAM WOOD & COMPANY MDCCCCXIII •*•• PREFACE TO THE THIRD ENGLISH EDITION Since the latest issue of this work has been exhausted there has been an ever-increasing demand for a new edition. The claims of Professor Kraepelin as a most original and successful teacher of clinical psychiatry require no advocacy, and his system, taking into consideration as it does the life-history of each separate condition, has made a permanent impression on the future.study and comprehension of Alienism. In producing this third English Edition, I have, wherever necessary, brought the matter up to date, and at the end of the volume (in the form of Appendices) will be found short articles on Maniacal Depressive Insanity, Dementia Praecox, and the Serum Diagnosis of General Paralysis of the Insane. Previous issues of this work have at once secured a most favourable and successful reception, and, indeed, unequalled by any modern work on this subject in recent years, and I trust this edition may meet with the same good fortune in every way. T. JOHNSTONE. Harrogate, October, 1912. PREFACE All those who have at any time given dinical demonstrations on disease must have felt the desire to impress more firmly on their hearers the remembrance of what they have seen than is possible in an ordinary lecture. After many attempts to arrive at this in some other way, I have now tried to preserve, in a measure, the impressions of a term's clinical work in the form of the lectures contained in the following pages. In my descriptions I have endeavoured, as far as possible, to follow the actual course of the lectures. Naturally, not only must this work give up all claim to the actual presentation of the patients, for which the student can only be compensated by personal experience in the hospital, but we must also forego the great help to teaching afforded by the assistant's little awkwardnesses and blunders, which so often serve to point out to the teacher the right method of instruction. On the other hand, the material can in this way be worked up more concisely, more systematically, and more completely than is generally possible in the hospital. In these lectures I have always kept the diagnostic point of view in the foreground, being convinced of its fundamental im- portance, not only to our scientific ideas, but also as affecting the advice we shall have to give in our medical practice, and the methods of treatment to be adopted by us. In my opinion, what the student ought to learn in the hospital, besides the examination of patients, is not text-book knowledge, which he can acquire just as well, or better, at home, but how to turn his obser\^dtions to account, and the careful judgment of any given case. These lectures, then, must not in any way be looked upon as a text- book of ahenism. Their aim will be far better attained if they prove of some value as a guide to the clinical investigation of the insane. vi Preface vii The examples of disease, which for obvious reasons have been taken from entirely separate years, and some of which have been utilized elsewhere, do not profess in their brief outline to be scientific records. Nevertheless, each individual case is deline- ated with the greatest possible truth to life, while the diagnostic developments are almost entirely taken directly from notes upon clinical demonstrations. Inquiries as to the further history of the patients were carried on, as far as possible, up to going to press, and, for the most part, were only added after the whole was complete. E. KRAEPELIN. Heidelberg. EDITOR'S PREFACE No apology is needed for the reproduction in English of any of Dr. Kraepelin's works. In the Author's Preface the precise aim and object of these chnical lectures is definitely stated, and for excellence they may be compared to those of Sir W. R. Gowers on a different branch of nervous study. In order that the subjects dealt with might be studied in regular sequence, I have constructed a table, placing together the subdivisions of each disease and the lectures in which they occur, so as to facilitate their continuous study. The importance of observing the periodicity of nervous diseases through long periods of time — a fact insisted on many years ago by the late Professor Laycock, of Edinburgh, and published in his book on the " Nervous Diseases of Women " — is emphasized in these lectures. Dipsomania is typically a " periodic disease," and when its cycle is annual the attack usually takes place in May or October ; but years often elapse ere the victim becomes what is known as a quarterly toper. As this condition is only fully established in adult life, the " equivalents " in the previous history of such patients might prove interesting speculatively. This "periodi- city" can also often be noticed in ordinary bodily ailments, and the usual day of many " neurotics " is a regular cycle, begin- ning with morning depression or morning activity, according as they are evening or morning workers. The various forms of puerperal mania might advantageously be termed reproductive insanity, because gestation is a trying physiological experiment on any nervous system, and there is no period from its pnset until the end of lactation at which the mental balance may not be disturbed. These lectures are eminently practical, very little space being devoted to the shifting sands of metaphysics and pathology. Since their appearance, however, a somewhat more hopeful field in nervous or mental pathology has been opened up by the work of Drs. Ford Robertson and McRae, in associating general paralysis of the insane with a bacillus as a possible cause. Should viii Editor's Preface ix these observations and experiments and others in the same direc- tion ultimately establish an etiological connection between such toxines and mental disease, then, judging from our clinical know- ledge of the varjang effects produced by different chemical toxines on the nervous system, and occasionally by the different effects caused by the same poison on different constitutions, we must be prepared to explain the phenomena produced by other toxines in a very liberal spirit. The translators have endeavoured to do their work faithfully, avoiding as far as possible the intro- duction of new technical terms, and where any have crept in, it is hoped they will be readily understood from the context. The nomenclature of the diseases adopted in the text differs widely from that met with in English books on the subject ; but any little difficulty here will be easily understood by a study of the table where the contents are classified — for example, the phases of the disease termed " maniacal-depressive insanity " only groups together phenomena which have long been recognised. Sir J. Batty Tuke, in his work on the " Insanity of Over- exertion of the Brain," speaking of these states, says : " Further, it must be remembered that, although in many cases the character of depression or exaltation is maintained throughout, a large class exists in which it is impossible to say whether they are melan- cholic maniacs or maniacal melancholies." No such practical lectures on this subject have appeared in recent years, and it is hoped that they may prove of interest and service to the general practitioner ; for it is he, in many instances, who has the first trouble and anxiety with acute mental ailments, and the teaching in these clinical lectures should enable him to be more ready for such emergencies. Though, as specified by Dr. Kraepelin in his preface to these lectures, the question of diagnosis always occupies the first place, that of treatment is never ignored. I should like to point out in particular the use of saline solutions and trans- fusions, which are recommended in acute asthenic states. It is of interest that this plan of treatment has occurred to Dr. Rutherford Gilmour, and has been practised by him with most gratifying results, so far. THOMAS JOHNSTONE. 32, Park Square, Leeds, April, 1904. CONTENTS LECTURE I INTRODUCTION : MELANCHOLIA PAGE Object of Psychiatry — Scientific and Practical Import of Mental Diseases — Points of Attack for Medical Interference — Simple Melancholia with Apprehension and Ideas of Sin — Melancholia with Suicidal Impulses — Melancholia with Delusions — Causes, Influence of Age — Results — Treatment- - - - i-io LECTURE II DEPRESSED STAGES OF MANIACAL-DEPRESSIVE INSANITY (CIRCULAR STUPOR) Circular Stupor — Impediment of VoUtion — Maniacal-depressive Insanity — Periodicity — Fluctuations in Body Weight — Circular Stupor with Impediment of Cognition — Slight Circular Depression vnth Ideas of Sin — Distinction from Melancholia — Mildest forms of Maniacal-depressive Insanity — Treatment - 11-20 LECTURE III DEMENTIA PRiECOX Simple Dementia — Emotional Dulness — FUghtiness — Laughing, Grimacing — Play on Words — Supposed Relation to Onanism — Initial Depression — Automatic Obedience, Catalepsy, Echo- praxis — Hallucinations, Ideas of Persecution — Acute Onset — Remissions _----.. 21-29 LECTURE IV KATATONIC STUPOR Negativistic Stupor — Stereotypism and Negativism — Katatonia or Insanity of Tension or Spasm — Terminations of Katatonic Stupor — Combined Automatic Obedience and Negativism — Slobbering — Relations to the Puerperium — Snout Cramp (Oral Spasm) — Characteristic Feeble-Mindedness ... 30-38 X Contents xi LECTURE V STATES OF DEPRESSION IN GENERAL PARALYSIS PAGE Resemblance to other States of Depression — Physical Signs and Symptoms — Inactivity of Pupils — Reflexes — Analgesis— " Dementia Paralytica " — Connection with Syphilis — Termina- tion of the Disease — Dementia with Hypochondriacal Ideas — Weakness of Memory — Disturbances of Speech and Writing — Cystic Derangements — Katatonic Signs — Specific Treatment — General Paralysis, a " Metasyphilis " — Initial Depression — Differentiation from Maniacal-depressive Insanity — Predispo- sition and Syphilis .----- 39-48 LECTURE VI EPILEPTIC INSANITY Epileptic Depression — Periodicity — Fainting Fits, States of Semi- consciousness—Relation to Alcohol — Epilepsy after Injuries to the Head — Irritability — " Equivalents " — Combined Epi- leptic and AlcohoUc DeUrium — " Petit Mai " — Pathological States of Intoxication — Deliriums — Treatment - - 49-58 LECTURE VII MANIACAL EXCITEMENT Hypomania — Alternation with States of Depression — Prognosis — Furious Outbursts of Temper — DivertibiUty — Fhght of Ideas — Fluctuations of Mood — " Press of Occupation " — Alternating Mild and Severe Attacks — " Periodical Mania " — Treatment by Bromides ....--- 59-68 LECTURE VIII MIXED CONDITIONS OF MANIACAL-DEPRESSIVE INSANITY Maniacal Stupor — Different Forms of Stupor — Impediment of Cognition and Volition with Abnormally Cheerful Mood — Depressive Excitement — Alternating Conditions — Maniacal- depressive Insanity with Delusions - - - - 69-78 LECTURE IX KATATONIC EXCITEMENT Confused Speech — Coprolalia — Impulsive Actions — Mannerisms — Alternation with Stupor — Severe Katatonic Excitement — Treatment — Remission with Degeneration of Character — Foolish Excitement with Hallucinations and Delusions - 7Q-88 PAGE xii Contents LECTURE X MEGALOMANIA IN GENERAL PARALYSIS Nature of Ideas of Grandeur in General Paralysis — Syllable Stum- bling—Classical General Paralysis— Alternating Depression and Grandiose Ideas — Long-continued Remissions (Lucid Intervals) —Diagnosis from the Mental Side— Galloping Excited Form of General Paralysis - - - - - - 89-98 LECTURE XI ALCOHOLIC MENTAL DISTURBANCES Delirium Tremens — Loss of Knowledge of External Surroundings — Hallucinations — Delirious Experiences — " Business Delirium '' — Prognosis — " Collected Delirium " — Physical Disturbances — Connection with Alcohol — Treatment — Alcoholic Mania — Rhythmical Hallucinations of Hearing - - 99-109 LECTURE XII INSANITY IN ACUTE DISEASES Initial Delirium in Typhus — Diagnosis — Prognosis — Treatment — Infectious State of Weakness after Erysipelas — Psychical En- feeblement — Acute Bewilderment after Arthritic Rheumatism — Confusion of Ideas — Meynert's Amentia - - 110-119 LECTURE XIII VARIETIES OF DELIRIUM Delirium in General Paralysis— Saline Transfusions in Asthenic Conditions — Combination with Alcoholic Delirium — Katatonic Delirium — Its Differentiation from Epileptic Delirium — Its Course in Individual Attacks — Treatment — Epileptic Delirium 120-130 LECTURE XIV PUERPERAL INSANITY Its Frequency — Katatonic Dementia during Pregnancy — Question of Acute Dementia — Influence of Parturition on the Disease — Apoplectic Attacks — State of Exhaustion in the Puerperium — Delirium of Collapse — Treatment — Choreic Insanity after Articular Rheumatism in the Puerperium — Real and Apparent Causes — Connection with Epilepsy — Treatment - 1 31-1 41 Contents xiii LECTURE XV PARANOIA, OR PROGRESSIVE SYSTEMATIZED INSANITY PAGE Various Clinical Meanings of Delusions and Hallucinations — Fixed and Systematized Delusions of Persecution and Grandeur ■without Alteration in Outward Bearing — Delusionary View of the World — " Derangement " — Absence of Hallucinations — Falsification of Memory — Protracted Course — Delusions of Querulous Persons — Struggle for "Justice" — Form of Degeneration - - - - - - 142 152 LECTURE XVI PARANOIDAL FORMS OF DEMENTIA PRiECOX Katatonia with Delusions — Appearance after Depression and Stupor — Disappearance of the Delusion — Dementia Paranoides — Pro- fusion of Unstable and Fantastic Delusions — Uniform Perma- nent Delusions with Hallucinations — Delusion of Physical and Mental " Influencing " - - . . 153-162 LECTURE XVII DIFFERENT FORMS OF DELUSIONS Delusion' of " Influencing " in General Paralysis — Tabic Paralysis — Senile Delusion of Persecution — Delusions of Jealousy — Poly- neuritic Mental Derangements with Delusions^Falsification of Memory — Part played by Alcohol - - . 163-773 LECTURE XVIII CHRONIC ALCOHOLISM Acute Alcoholism — After-effects — Alcoholic Loss of Will-power — Looseness of Speech in Drunkards — Incapacity for Work — Treatment — Severe Form of Alcoholism — Alcoholic Delusions of Jealousy — Their Dangerous Character — Periodical Alco- holism— Dipsomania — Connection with Depression — Epileptic Basis --.---- 174-182 LECTURE XIX MORPHINISM AND COCAINISM Slighter Form of IMorphinism — Pain following an Injury as the Starting-point — Hypodermic Scars — Signs of Chronic Poison- ing— Morphine Hunger — Slavery to the Drug — Withdrawal of Morphine — Treatment — Relapses — Severe Morphinism — Loss of Will-power — Alcoholic Delirium during the Cure — Cocaine — Morpho-cpcainism — Alcohol and Cocaine Delirium — Responsi- bility of Medical Men ----- 183-192 CAGE xiv Contents LECTURE XX FINAL STAGES OF GENERAL PARALYSIS OF THE INSANE Importance of the Course and Termination for Clinical and Practical Opinion — Termination of General Paralysis — Characteristic Mental Weakness with Palsy — Demented Form of General Paralysis — Acute and Chronic Forms — Simple Paralytic De- mentia after Depression and Excitement with Delusions — Fluc- tuations in Body-weight — Metabolic Disturbances — General Paralysis in Women — Paralytic Attacks— Their Different Forms— Treatment — Termination of the Disease — Autopsy — Atypical Paralysis ----- 193-203 LECTURE XXI FINAL STAGES OF DEMENTIA PRiECOX Variety of Terminations — Different Forms of Dementia — Katatonic Feeble-mindedness developing by interrupted but increasingly Severe Attacks — Katatonic Dementia with Confused Speech and " W^ords of the Patient's own Invention " — Katatonic Attacks — Katatonic Dementia with Periodical Excitements 204-214 LECTURE XXII DEMENTIA FROM COARSE BRAIN LESIONS Apoplectic Dementia with Monophrasia — Arterio-sclerotic Lesion of the Brain — Distinction from General Paralysis and Brain Syphilis — SyphiUtic Lesion of the Brain — Differentiated Diagnosis ..-..- 215-227 LECTURE XXIII SENILE DEMENTIA Simple Senile Dementia — Disturbance of the Faculty of Attention to New Impressions — Strange Fancies — Presbyophrenia — Senile Katatonia . . . . . 228-237 LECTURE XXIV EPILEPTIC FEEBLE-MINDEDNESS Permanent Changes as the Basis of Periodical Disturbances — Charac- . teristics of Epileptic Feeble-mindedness — Clumsiness — Narrow- ing of the Mental and Emotional Horizon — Obstinacy and Pedantry — Irritability and Piety — Marked State of Semi-con- sciousness in Advanced Epileptic Dementia — Differential Diagnosis — Late Development of Epilepsy — Injury to the Head and Alcohol — Diagnostic Symptoms of Alcoholic Epilepsy 238-248 Contents xv LFXTURE XXV HYSTERICAL INSANITY PAGE Severe Hysteria — Sleeping Attacks, and States of Semi-consciousness — Suggestibility — Nature of the Disease — The Hysterical Character — Hysteria in Children — Connection with Defective Mental Development — Hysteria in Men — Traumatic Hysteria — Combined with Alcoholism — Arson committed in the Semi- conscious State - - - - . . 249-258 LECTURE XXVI INSANITY AFTER INJURIES TO THE HEAD Difificulty of establishing the Connection — Traumatic Bewilder- ment— Disturbance of Memory — Traumatic Dementia — Altera- tion of Character — " Concussion of the Brain " — Traumatic Neurosis — Question of Malingering — Psychical Methods of Examination — Prognosis and Treatment — Relations to Hys- teria -------- 259-269 LECTURE XXVII IRREPRESSIBLE IDEAS AND IRRESISTIBLE FEARS Permanent Psychopathic Inferiority — Irresistible Fears of Various Kinds — Hypochondriasis — Treatment — Hysteria after an In- jury, with Irresistible Fears — Irrepressible Ideas in Maniacal- depressive Insanity ----- 270-279 LECTURE XXVIII CONGENITAL STATES OF DISEASE Degeneration — Psychopathic Personalities with Homosexual Ten- dencies— Various Forms of Sexual Aberration — Sadism — Maso- chism— Fetischism — Their Origin — Morbid Castles in the Air — Constitutional Excitement — Connection with Maniacal- depressive Insanity — Periodical Depression — Constitutional Morbidity of Mood ... - - 280-294 LECTURE XXIX MORBID PERSONALITIES Definition of Morbidity — Morbid want of Self-control — ^Morbid Liars and Swindlers — Difference between Legal and Medical Stand- points—Pseudo-querulous Cases — Their Distinction from Cases of Querulous Delusion ----- 295-309 PAGE xvi Contents LECTURE XXX MORBID CRIMINALS AND VAGABONDS Habitual and Professional Criminals — Impulsive Arson — Criminals by Impulse — Arrested Moral Development — Moral Insanity and Born Criminals — A Psychopathic Vagabond — Part played by Alcohol — Various Groups of Vagabonds - - 310-325 LECTURE XXXI IMBECILITY- IDIOCY Simple Congenital Feeble-mindedness — Comparison with Puerile Stages of Development — Differentiation from Sanity and from Acquired Feeble-mindedness — Object and Outcome of Educa- tion in Imbeciles — Idiocy— Defective Development of Speech — Physical Foundations of Idiocy — Connection with Epilepsy — Idiocy with Emotional Dulness - - - 326-335 LECTURE XXXII CRETINISM— CONCLUDING REMARKS Arrest of Physical and Mental Development with Myxcedema — Endemic Cretinism — Thyroid Treatment — Classification of Mental Disturbances in Accordance with their Causes — Cessa- tion of Certain Bodily Functions in Cretinism — Fundamental Subversion of the Physical Economy in General Paralvsis, Dementia Prajcox, and Epilepsy — Entrance into the Body of Infectious Toxins — Direct and Indirect Effects of Toxins produced by Indulgence — Exhaustion — Coarse Disturbances of the Cortex — Concussion of the Brain — Idiosyncrasy — Periodical Attacks and Permanent Morbid Conditions - 336-345 INDEX --...-- 346-352 CLASSIFICATION OF MENTAL DISEASES H Z <; IS I— I O S H w I— I < > INTRODUCTION MELANCHOLIA - MANIACAL -DEPRESSIVE CONDITIONS DEMENTIA PR^.COX GENERAL PARALYSIS (of THE insane) - DEPRESSED CONDITIONS MANIACAL EXCITEMENT MIXED CONDITIONS - DEMENTIA PR.*;COX - PARANOIDAL FORMS- FINAL STAGES STATES OF DEPRESSION STATES OF GRANDEUR FINAL STAGES KATATONIA KATATONIC STUPOR - KATATONIC EXCITEMENT PARANOIA (MONOMANIA, PROGRESSIVE SYSTEMATIZED INSANMY) . _ - . . AFTER ACUTE DISEASES (DELIRIUM OF COLLAPSE) AFTER HEAD INJURIES (tRAUMATIC) - - - EPILEPTIC --.... HYSTERICAL ------ PUERPERAL ------ I MX .COHOLIC MENTAL DISTURBANCES ALCOHOLIC ; CHRONIC ALCOHOLISM (COMlilNED FORMS) - - - - MORAL j CONGENITAL STATES OF DISEASE <, MORBID PERSONALITIKS- ( MORBID CRIMINALS AND VAGABONDS MORPHINISM, COCAINISM ta o > H C/3 a ►J H ^ i w w oi S < ACQUIRED or) DEMENTIA - | CONGENITAL OR ORDINARY - FROM COARSE BRAIN LESIONS OLD AGE (senile) EPILEPTIC EPILEPTIC IMBECILITY- CRETINISM -IDIOCY VARIETIES OF DELIRIUM VARIETIES OF DELUSIONS - IRREPRESSIBLE IDEAS AND IRRESISTIBLE FEARS CRETINISM — CONCLUDING REMARKS LECTURE I. L II. VI I. VIII. III. XVI. XXI. V. X. XX. IV. IX. XV. XII. XXVI. VI. XXV. XIV. XI. XVIII. XXVIII. XXIX. XXX. XIX. XXII. XXIII. XXIV. XXIV. XXXI. XXXII. XIII. XVII. XXVII. XXXII. T. JOHNSTONE. NOTE Just as the second edition of the English Translation of Kraepelin's ' Clinical Psychiatry ' is going through the press, the Statistical Committee of the Medico-Psychological Association have published their report and new tables. While recognising the value of the work as a whole, I do not see any reason for altering the Classification of ]\Iental Diseases which I have drawn up in accordance with the teachings of Professor Kraepelin. THOMAS JOHNSTONE. 32, Park Square, Leeds. October 20, 1905. INTRODUCTORY LECTURES ON CLINICAL PSYCHIATRY LECTURE I INTRODUCTION : MELANCHOLIA Gentlemen, — The subject of the following course of lectures will be the Science of Psychiatry, which, as its name implies, is that of the treatment of mental disease. It is true that, in the strictest terms, we cannot speak of the mind as becoming dis- eased, whether we regard it as a separate entity or as the sum total of our subjective experience. And, indeed, from the medical point of view, it is disturbances in the physical founda- tions of mental life which should occupy most of our attention. But the incidents of such diseases are generally seen in the sphere of psychical events, a department with which the art of medicine has dealt very little as yet. Here we are not so much concerned with physical changes in size, shape, firmness, and chemical com- position, as with disturbances of comprehension, memory and judgment, illusions, hallucinations, depression, and morbid changes in the activity of the will. With the help of the ideas you have deiived from general pathology, you will usually be able to find your way in a new department of medicine without any serious difficulty. But here you will be utterly perplexed at first by the essentially peculiar phenomena of disease with which you will meet, until you have gradually learned to a certain extent to master the special symptomatology of mental disturbances. Of course, you will sometimes have met with isolated conditions of mental disease in everyday life, or in other hospitals — intoxica- tion, fever delirium, and delirium tremens, or even imbecility I 2 Lectures on Clinical Psychiatry and idiocy — but the^' may have impressed you more as strange and incomprehensible curiosities than as adding to your stock of medical ideas. Insanity works a change in the mental personality, that sum of characteristics which, to our minds, represents a man's real being in a far higher degree than his physical peculiarities. Hence, our patient's whole relation to the outside world is affected in the most comprehensive way. The knowledge of all these dis- turbances is a fruitful field for the investigation of mental life, not only revealing man}' of its universal laws, but also giving a deep insight into the history of the development of the human mind, both in the individual and in the race. It also provides us with the proper scale for comprehending the numerous intellec- tual, moral, religious, and artistic currents and phenomena of our social life. But it is not these variously branching scientific relations to so many of the most important questions of human existence which make a knowledge of psychical disturbances indispensable to the physician ; it is rather their extraordinary practical importance. Insanity, even in its mildest forms, involves the greatest suffering that physicians have to meet. Only a comparatively small per- centage of mental cases are permanently and completely cured in the strictest sense of the word. And the number of the insane, which will hardly be exaggerated if we estimate it as amounting at the present moment to 200,000 in Germany alone, is appar- ently increasing with the most unfortunate rapidity. This increase may depend, to a great extent, on our fuller knowledge of insanity, on the more highly-developed care of the insane, and on the increasing difficulty of treating them at home, and so may be only apparent. But, considering that from one-quarter to one- third of the cases admitted to our asylums are due to the abuse of alcohol or to syphilitic infection, and that these are causes of which the extension is certainly not diminishing, we cannot but suppose that the number of the insane is increasing, not only in itself, but also in its proportion to the population. The growing degeneration of our race in the future may therefore still be left an open question, but certainly it might be very greatly promoted by both these causes. All the insane are dangerous, in some degree, to their neigh- bours, and even more so to themselves. Mental derangement is the cause of at least a third of the total number of suicides. Introduction : Melancholia 3 while sexual crimes and arson, and, to a less extent, dangerous assaults, thefts, and impostures are often committed by those whose minds are diseased. Numberless families are ruined by their afflicted members, either by the senseless squandering of their means, or because long illness and inability to work have gradually sapped the power of caring for a household. Only a certain number of those who do not recover succumb at once. The greater part live on for dozens of years, imbecile and helpless, imposing a heavy and yearly increasing burden on their families and communities, of which the effects strike deeply into our national life. For all these reasons, it is one of the physician's most important duties to make himself, as far as possible, acquainted with the nature and phenomena of insanity. Even though the limits of his power against this mighty adversary are very narrow, oppor- tunity enough is afforded to every practical physician to contri- bute his share to the prevention and alleviation of the endless misery annually engendered by mental disease. Alcoholism and syphilis undoubtedly offer the most profitable points of attack, together with the abuse of morphia and cocaine, which so clearly owes its fatal significance to the action of medical men. Family physicians, again, can often help to prevent the marriage of the insane, or of those who are seriously threatened with insanity, and to secure a proper education and choice of occupation for children predisposed to disease. But it will be their special province to recognise dangerous symptoms in time, and, by their prompt action, to prevent suicides and accidents, and obviate the short-sighted procrastination which only too often keeps patients from coming under the care of an expert alienist until the time for practically useful treatment has long been past. Even in those numerous cases which never become insane in the narrower sense, the physician who has been trained in alienism will have such an understanding of the recognition and treatment of psychical disturbances as will amply repay him for the trouble of his years of study. Even in my own experience it has hap- pened very often that older physicians have regretted their defective knowledge of alienism, -and complained that it was only in practical life that they learned how great a part is played, m the daily round of ordinary medical practice, by the correct diagnosis of more or less morbid mental incidents. I need hardly mention that, for various reasons, such a diagnosis is in I — 2 4 Lectures on Clinical Psychiatry constant demand by public authorities, courts of law, and trade societies. Of course, an intimate knowledge of Psychiatry, as of every other separate branch of medicine, can only be acquired by long and thorough occupation with the subject. Yet, even in a short time, it is possible to cast at least a general and superficial glance over the commonest forms of mental disturbance. Personal in- vestigation and continuous observation of the greatest possible number of different cases are indispensable to this, and it is only too true that, even after one or two terms of zealous clinical study, thtre will still be many cases which the beginner is unable to interpret correctly by means of the knowledge with which he has been furnished or which he has acquired for himself. But one important advantage to be gained comparatively quickly is a recognition of the great difficulties of the subject and the correc- tion of that simple-minded ignorance, still so widely spread, which assvunes that even a non-expert may give an opinion on mental cases without any more ado. After these introductory remarks, let us turn to the considera- tion of our patients. 1 will first place before you a farmer, aged fifty-nine, who was admitted to the hospital a year ago. The patient looks much older than he really is, principally owing to the loss of the teeth from his upper jaw. He not only understands our questions without any difficulty, but answers them relevantly and correctly ; can tell where he is, and how long he has been here ; knows the doctors, and can give the date and the day of the week. His expression is dejected. The corners of his mouth are rather drawn down, and his eyebrows drawn together. He usually stares in front of him, but he glances up when he is spoken to. On being questioned about his illness, he breaks into lamenta- tions, saying that he did not tell the whole truth on his admission, but concealed the fact that he had fallen into sin in his youth and practised uncleanness with himself ; everything he did was wrong. " I am so apprehensive, so wretched ; I cannot lie still lor anxiety. O God, if I had only not transgressed so griev- ously !" He has been ill for over a year, has had giddinv^ss and headaches. It began with stomach-aches and head trouble, and he could not work any longer. " There was no impulse left." He can get no rest now, and fancies silly things, as if someone were in the room. Once it seemed to him that he had seen the Evil One : perhaps he would be carried off. So things seemed to him. Introduction : Melancholia 5 As a boy, he had taken apples and nuts. " Conscience has said that that is not right ; conscience has only awakened just now in my illness." He had also played with a cow, and by himself. " I reproach myself for that now." It seemed to him that he had fallen away from God, and was now as free as a bird. His appe- tite is bad, and he has no stools. He cannot sleep. " If the mind does not sleep, all sorts of thoughts come." He has done silly things too. He fastened his neckerchief to strangle himself, but he was not really in earnest. Three sisters and a brother were ill too. The sisters were not so bad ; they soon recovered. " A brother has made away with himself through apprehension." The patient tells us this in broken sentences, interrupted by wailing and groaning. In all other respects, he behaves naturally, does whatever he is told, and only begs us not to let him be dragged away — " There is dreadful apprehension in my heart." Except for a little trembling of the outspread fingers and slightly arhythmic action of the heart, we find no striking disturbances at the physical examination. As for the patient's former history, he is married, and has four healthy children, while three are dead. The illness began gradually seven or eight months before his admission, without any assignable cause. Loss of appetite and dyspepsia appeared first, and then ideas of sin. His weight diminished a little after his admission, but has now slowly risen again 7 kilogrammes. The most striking feature of this clinical picture is the appre- hensive depression. At first sight, it resembles the anxieties of a healthy person, and the patient says that he was always rather apprehensive, and has only grown worse. But there is not the least external cause for the apprehension, and yet it has lasted for months, with increasing severity. This is the diagnostic sign of its morbidity. It is true that the patient himself refers to the sins of his youth as the cause of the apprehension, but it is clear that, even if they were ever really committed, they did not particularly disturb him before his illness ; his conscience has only awakened now. His actions now appear to him in an entirely different and fatal light, and those morbid symptoms become prominent which are known as " delusions of sin." The patient's ideas that the Evil One was in the room, that he would be carried off, and that he had fallen away from God, must be regarded as a result of his apprehension. There is no question of real hallucinations in these statements ; it only seemed so to 6 * Lectures on Clinical Psychiatry the patient. He also has a strong feeling that some great change has come over him, and that he is " not the same as before." He is certainly not in a condition to form a correct conception of the morbidity of his ideas of sin and of his fears in detail. We give the name of melancholia to this condition, in which we see the gradual development of a state of apprehensive depression, associated with more or less fully-developed delusions. The most common of these are ideas of sin, which generally have a religious colouring. Such are the ideas of having fallen away from God and being forsaken, or of being possessed by the devil. Hypochondriacal ideas— of never being well again, never having a stool again, etc. — are also far from uncommon. Together with these there is often apprehension of poverty, of having to starve, of being thrown into prison, of being brought before a court, or even of execution. As a consequence of this mental unrest and these tormenting ideas, the wish to have done with life develops almost invariably, and patients very often become suicidal. Our first patient only made a rather feeble attempt at suicide, but I will now show you a widow, aged fifty-four, who has made very serious efforts to take her own life. This patient has no insane history. She married at the age of thirty, and has four healthy children. She says that her husband died two years ago, and since then she has slept badly. Being obliged to sell her home at that time, because the inheritance was to be divided, she grew apprehensive, and thought that she would come to want, although, on quiet consideration, she saw that her fears were groundless. She complained of heat in her head and uneasiness at her heart, felt weak and excited, and was tired of life, especially in the morning. She says she could get no sleep at night, even with sleeping-powders. Sud- denly the thought came to her, " What are you doing in the world now } Try to get out of it, so as to be at rest. It's no good any ;onger," Then she hung herself up behind the house with her handkerchief, and became unconscious, but her son cut her down and brought her to the hospital. Here she was quite collected, and was orderly in thought and behaviour. She understood the morbidity of her condition, but feared that she would never be well again. She said she could not bear it any longer, and could not stay here ; she was driven to despair. She was very fond of talking about her condition, and loudly lamented that she was so apprehensive, asking for a Introduction : Melancholia 7 clergyman to come and drive out the Evil One. At this she was seized with violent trembling in her whole body, and declared that she had no peace ; she could not rest, her heart beat so ; her head was bursting, she could not live any longer ; she wished to die at home ; thoughts of suicide tormented her unceasingly. Her sleep and appetite were bad, but no other physical disturb- ance could be discovered. In the course of the first few months her mental condition improved fairly quickly, and, at the urgent desire of her relations, leave of absence was granted with the family of her daughter. But the apprehension and thoughts of suicide became so marked that she had to be brought back to the hospital within a fortnight. Here her condition is still improving, though very slowly and with many fluctuations. Her recovery has been much delayed by a carious affection of the right parietal bone and the left wrist, which necessitated repeated inter- ference, but is now in a tolerably healthy condition. This patient, too, is quite clear as to her surroundings, and gives connected information about her condition. She has no real delusions, apart from fear that she will never be well again. Indeed, we find that the real meaning of the whole picture of disease is only permanent apprehensive depression, with the same accompaniments as we see in mental agitation in the sane — i.e., loss of sleep and appetite, and failure of the general nutrition. The resemblance to anxiety in a sane person is all the greater because the depression has followed a painful external cause. But we can easily see that the severity, and more especially the duration, of the emotional depression have gone beyond the limits of what is normal. The patient herself sees clearly enough that her apprehension is not justified by her real position in life, and that there is absolutely no reason why she should wish to die. This sense of the morbid nature of the apprehension, or " in- sight into the disease," is not always present in melancholia. In those cases, more especially, in which there are marked delusions this important symptom may be altogether absent for a long time together. As an example, I will show you a widow, aged fifty-six, who nursed her son when he was ill of typhus two and a quarter years ago. She then had a feverish illness herself, presumably also typhus, and lost her husband suddenly a few months later. Very soon after this she began to be apprehen- sive, and to reproach herself with not having taken proper care of her husband. Strongly-marked delusions of sin quickly de- 8 Lectures on Clinical Psychiatry veloped. She had never done anything properly, and had allowed herself to be led away by the wicked fiend. Her prayers had been no good, only she did not know that before. Her husband absolutely married the devil, and could not go to heaven, and she and her children were damned on account of her former unchristian life. Great restlessness and almost complete sleep- lessness now came on. The patient lamented, shrieked, and wept persistently, her appetite quite failed, and she soon had to be brought to the hospital. Here she was collected and clear about her surroundings, but gradually passed into a very severe state of apprehensive excite- ment, which found expression in monotonous and almost in- tolerable shrieks. She could only be interrupted for a short time by asking her questions, which she always answered. She also expressed a quantity of the most fantastic ideas. She had been the serpent in paradise, had led astray her husband, who was called Adam, and had made herself and her children accursed, and everyone unhappy. Therefore she was burning, was already in hell, and saw her fearful sins in the abyss. The firmament had fallen ; there was no more water or money or food ; she had ruined everything, and was guilty of the downfall of the world — " The whole world lies upon my soul." She accused herself of all these transgressions in a written document, addressed to the District Court, and begged to be taken to prison. She wrote her name on a label as " Devil." In spite of all this, you are soon convinced that, even while she is senselessly shrieking and expressing delusionary ideas of this kind, the patient knows where she is quite well, knows the doctors, and gives broken but relevant answers to questions about the circumstances of her home. She also does sums correctl}', though she returns at once to her monotonous lamentations. Some- times it appears that she has a certain understanding of her illness. "One fancies first one thing and then another," she says. " It often seems quite different to me, as if it were not so. It often seems as if it were a dream, and often as if it were reality." As the result of sleeplessness and insufficient nourish- ment, she is physically quite run down, but shows no other sign of illness. She has three healthy sons,* while three of her children died in childhood. Her father is said to have been temporarily insane. * One of them afterwards developed katatonia, and became demented. Introduction : Melancholia 9 At first sight this clinical picture of disease seems different from the other and simpler forms. But it is easily shown that the variations are only a matter of degree. Both in the develop- ment of the delusions and in the strength and manifestations of the apprehension we meet with every conceivable transition, from the form first described and generally known as melancholia simplex to the present morbid condition, and to even more marked cases. Often enough the same patient presents first one and then another type of symptoms at different times. It is therefore impossible to lay down any reliable clinical line of division in these cases. All three patients are of considerable age. This is not an accident. Melancholia, as we have described it here, sets in principally, or perhaps exclusively, at the beginning of old age in men, and in women from the period of the menopause onwards. We might regard it as a morbid expression of the feeling of growing inadequacy, usually more or less noticeable in healthy people of the same age. Those who are morbidly disposed by nature of course become melancholic most easily, as is shown by our examples, and women seem more inclined to the disease than men. Of external influences, emotional shocks, and especially the death of near relations, often figure as the exciting cause, although they cannot be regarded as the original cause, on account of their absence in other cases. The termination of the illness is generally pretty favourable.* About a third of the patients make a complete recovery. In severe and protracted cases, emotional dulness may remain, with faint traces of the apprehensive tendency. Judgment and memory may also undergo considerable deterioration. The course of the disease is always tedious, and usually continues, with many fluctuations, for from one to two years, or even longer, according to the severity of the case. The treatment of the malady cannot, as a rule, be carried out, except in an asylum, as thoughts of suicide are almost always present. Patients who show such tendencies require the closest watching, day and night. They are kept in bed and given plenty of food, though this is often very difficult, on account of their resistance. Care is also taken to regulate their digestion, and, * The first of these three patients has been well for more than nine and a half years, and the second for five years. The third died of pulmonary consumption, after four and a half years' illness, while sti.l uncured. lO Lectures on Clinical Psychiatry as far as possible, to secure them sufficient sleep by means of baths and medicines. Paraldehyde is generally to be recom- mended, or, under some circumstances, alcohol, or occasional doses of trional. Opimn is employed to combat the apprehen- sion, in gradually increasing doses, which are then by degrees reduced. This remedy has often done very good service with our first two patients, while with the third we have had better results from small doses of paraldehyde. Great care is needed in discharging patients. If this is done too soon, as in the case of our second patient, serious relapses may result, with attempted suicide. Visits from near relations have a bad effect up to the very end of the illness. LECTURE II DEPRESSED STAGES OF MANIACAL-DEPRESSIVE INSANITY (CIRCULAR STUPOR) Gentlemen, — The patient you see before you to-day is a mer- chant, forty-three years old, who has been in our hospital almost uninterruptedly for about five years. He is strongly built, but badly nourished, and has a pale complexion, and an invalid expression of face. He comes in with short, wearied steps, sits down slowly, and remains sitting in a rather bent position, staring in front of him almost without moving. When ques- tioned, he turns his head a little, and, after a certain pause, answers softly, and in monosyllables, but to the point. We get the impression that speaking gives him a great deal of trouble, his lips moving for a little while before the sound comes out. The patient is clear about time and place, knows the doctors, and says that he has been ill for more than five years, but can- not give any further explanation of this than that his spirits are affected. He says he has no apprehension. He gives short and perfectly relevant answers to questions about his circumstances and past life. He does exercises in arithmetic slowly but cor- rectly, even when they are fairly hard. He writes his name on the blackboard, when asked to do so, with firm though hesitating strokes, after having got up awkwardly. No delusions, par- ticularly ideas of sin, can be made out, the patient only declaring that he is in low spirits, without knowing of any cause for it, except that his illness has lasted so long, and worries him. He hopes, however, to get well again. As you may see, it is evident that in reality we have to deal with emotional depression in this case, as well as in those already discussed. It is true that there are no delusions associated with it here, as there were in the other cases ; but let us not be II 12 Lectures on Clinical Psychiatry inclined to lay too much stress on this, after having learned by experience how widely delusions may vary in the same illness. On the other hand, it must strike us that this patient is not apprehensive, but only " low-spirited," and still more that, unlike the patients already considered, he is apparently unable to move and express himself freely. In those cases there were lively gesticulations, lamentations, and complaints, and a certain necessity of giving vent to the oppression within, while here it is hard to draw any remark from the patient on his mental condition, or on questions of fact. This very circum- stance, that the answers come so slowly, even on matters of indifference, shows that in this patient we have not to deal with a fear of expressing himself, but with some general obstacle to utterance in speech. Indeed, not only speech, but all action of the will is extremely difficult to him. For three years he has been incapable of getting up from bed, dressing, and occupying him- self, and since that time has lain in bed almost without moving. But as he has the most perfect comprehension of his surround- ings, and is able to follow difficult trains of thought, the dis- turbance must be essentially confined to the accomplishment of voluntary movements, or at any rate must find by far its strongest manifestations in this direction. We clearly recognise the pains he takes to act and to comply with our demands, and at the same time the delay and difficulty attending every effort of the will. Under these circumstances, it will be permissible here to speak of an impediment of volition, in the sense that the transformation of the impulses of the will into action meets with obstacles which cannot be overcome without difficulty, and often not at all by the patient's own strength. This constraint is by far the most obvious clinical feature of the disease, and compared with this, the sad, oppressed mood has but little prominence. No other psychical disturbances can be made out at present. Having established this, we have got an insight, on several points, into the nature of the disease before us. In the first place, we see that this condition differs from that of our melan- cholic patients, in a very definite way, through the strong impedi- ment of volition, and the absence of the apprehensive restless- ness so clearly marked in them. Experience shows that this condition is very characteristic of an entirely different disease, to which we will give the name of maniacal-depressive insanity^ Stages of Maniacal-Depressive Insanity 13 for reasons to be discussed immediately. This disease generally runs its course in a series of isolated attacks, which are not uni- form, but present either states of depression of the kind described or characteristic states of excitement, which we will learn to know better later on. The isolated attacks are generally sepa- rated by longer or shorter intervals of freedom. The conclusion we have drawn from our patient's present con- dition is correct. He first became ill when he was twenty-three years old, and was then depressed, as is generally the case in first attacks ; but the depression was followed next year by a state of excitement, which led to his being brought to the asylum. Two years later he married a person very much beneath him, very probably when under slight excitement, but separated from her during the depression which ensued. At the age of thirty- one, probably when again in an excited state, he fell into the hands of an adventuress, who abandoned him when he became depressed again. Indeed, his relations held his depression to be the result of the melancholy experience he had been through. In his thirty-sixth and thirty-seventh years a further and stronger excitement followed, which again made treatment in the asylum necessary. The patient's father, as well as his two brothers, were drunkards, while his sister was ill in the same way as himself. He suffered for several years from diabetes insipidus. A doctor advised him, presumably on this account, to take a little wine, as too much water was not good for him. The patient followed this advice, and about five and a half years ago he suddenly fell ill of delirium tremens, immediately followed by a state of excitement, gradually and continually growing worse, which only disap- peared slowly after two years. Only a few weeks after his dis- charge from our hospital, where he was then treated, the extra- ordinarily severe impediment of volition which you may still observe in a milder form set in rather suddenly. The patient remained motionless in bed, would not eat, was wet and dirty in his habits, could hardly speak, and expressed apprehensive ideas. Thought also seems to have been affected at first, and the patient made no answer, or replied only very slowly, alike to emphatic and to gentle questionings. But there were no actual delusions even then. The patient soon returned to the hospital, but in spite of the most careful nursing, his condition has improved only very slowly and immaterially in the course 14 Lectures on Clinical Psychiatry of the last three j^ears. Yet we may expect that this attack also will end in recovery, like those which have preceded it, if only the patient can live through so severe a disturbance.* But it is no less probable that he will again fall ill of attacks of depression or excitement such as he has so often had before. Fluctuations of weight are of special interest in the disease we are now discussing. In the last attack of excitement he had in the hospital our patient lost nearly 13 kilogrammes, and then gained 25 kilogrammes when he became calm . In the first eighteen months of the depression, his weight fell from 91-5 kilogrammes to 56-5 kilogrammes, and has only risen 14 kilogrammes since. These figures show the violent revolutions in the province of general nutrition which take place in diseases of this kind. Little as we are yet able to account for the details of these occurrences, regular and continuous weighings afford us an excellent means of judging of the general state of the disease in this as in most other forms of insanity. A decided increase in the previously reduced weight in maniacal-depressive insanity is the most reliable sign that the attack has passed its worst. In the light of the case we have just considered the meaning of what follows will, I think, be clearer to you than it formerly was to me. Here is a case of a woman, twenty-three years old, who was admitted only a fortnight ago. The patient, whose mother is mentally rather limited, bore her second child six weeks ago. Seventeen days later she got a great fright from a fire in her room, and she then became apprehensive and rest- less, saw flames, black birds and dogs, heard whistling and singing, began to pra}-, screamed out of the window, lamented her sins, promised to be good, and could not sleep. The patient is ill-nourished and anaemic. She sits almost motionless, with her eyes cast down, staring in front of her, and moving her lips slightly now and then. Her expression is strained, and rather apprehensive. When questioned about dates, the place where she is, and the people about her, she either makes no answer at all, or shakes her head, or says in a low, hesitating voice : " I do not know." She nods when I ask her if she is unhappy, and mutters to herself : " There are always so many carriages * Unfortunately, this expectation was not realized. The psychical disturbances still continued, and the patient succumbed to acute phthisis when the depression had lasted three and a half years. Stages of Maniacal-Depressive Insanity 1 5 coming ; a great number drive about outside." Now and then she uses isolated, broken expressions, in a tone of lamentation, often repeating them one after the other : " I want to go home, to get out. Alas ! alas ! only let me go away. I will not let myself be done to death. I cannot stay here. Good heavens ! there is poison in the food !" She obeys orders with hesitation, and sometimes resists, but can plainly be influenced by persua- sion. When threatened with a needle, she screams and turns away hastily. She generally has to be fed. On consideration of the want of freedom in our patient's bearing, and the slowness and constraint of her movements, which only become more active in apprehensive gestures of self-defence, you will clearly see that, in this case, too, we have to deal with an impediment of volition, particularly apparent in the almost entire falling off of utterance in speech and of expres- sive movement. But it presents a contrast with the previous case in the more definite apprehension, which is far less amenable to persuasion and influence, and also by the severe disturbance of comprehension. The patient has absolutely no clear idea of her position, does not understand what goes on around her, and cannot solve any mental problems. A similar difficulty in thought is associated with the difficulty in the action of the will. You will remember that a disturbance of this kind occurred at the beginning of the last patient's attack, and that it was only later on that it became less and less obvious. This impediment of cognition, as we will call it, is in fact a symptom regularly accompanying the state of depression in maniacal- depressive insanity. It is sometimes more, sometimes less clearly defined, and is generally perceived very plainly by the patients themselves. As the intensity and colouring of the emotional depression may vary very widely in maniacal-depressive insanity, we will conclude, in consideration of the well-defined impediment of volition and cognition, that the case which is before us now belongs to the same group of diseases as the last case. Hence, it would seem probable that similar attacks, and also attacks of excitement, will clearly be noticed sooner or later in our patient. This conclusion is confirmed by the remarkable fact that, although she is so apprehensive, she begins, after a good deal of persuasion, to twist her face into an extraordinary smile. You will understand the meaning of this symptom at once if 1 6 Lectures on Clinical Psychiatry we glance back into the past. The patient was here four years ago. At that time she had aborted, after having been pregnant by a married man. A few weeks later she became dmnb and rigid, expressed ideas of death, saw spirits, grew quite confused, mixed, perplexed, and apprehensive, and refused to eat — in short, a state of impediment of volition and cognition was developed very like the present condition, but even more severe, lasting about seven months. Then, quite suddenly, there was a complete change, and the patient became clear and collected, and was in high spirits. Finally, she passed through a very violent state of excitement, which gradually disappeared after nearly six months. During her convalescence, there was slight and transitory emotional depression, but after this the patient became well, and remained so till the beginning of the present attack. Thus we see that the conclusion drawn from the patient's present condition was correct. The similarity of the two periods of depression of which we know leaves no room for reasonable doubt that they both belong to the same clinical picture of disease. We must indeed notice that both attacks followed a confinement, so that the same cause might have pro- duced the same illness each time. But we saw the same char- acteristic symptoms of impediment of thought and will in the preceding case, where there had been no confinement, and the subsequent change from depression to excitement, occurring in the same way in both patients, is a fresh proof that our case is one of maniacal-depressive insanity. We will see later on that those representations of disease in which we really have grounds for regarding a confinement as the actual cause present entirely different clinical features. Finally, experience shows that single attacks of maniacal-depressive insanity are very often set free by injurious external influences. We must, there- fore, expect our patient's next attack to break out once again without any very tangible cause. On the strength of these considerations, we may venture to suppose that the patient will often fall ill again in the luture course of her life, either of depression, as on this occasion, or of excitement, but that each attack may be expected to end in recovery. In the present attack, this may certainly be expected, yet it is very possible that a slighter state of excitement may Stages of Maniacal-Depressive ^Insanity 17 first intervene, as has happened before.* The smile already mentioned might be the first sign of such a change. The condition of severe impediment of volition is generally included with some other and outwardly similar states under the name of stupor. We may call the form now before us ' circular stupor," as maniacal-depressive insanity is often called circular insanity {folie circnlaire), on account of the cycle of recurrent conditions. The common characteristic of all forms of stupor is the absence of expression in speech or other- wise in response to external influences. Stupor is, however, no uniform condition, much less a separate disease, but a symptom which may arise from very different causes, and therefore may have very different clinical meanings. Even circular stupor meets us in such various forms that it is often difficult to recog- nise their real agreement. Here you see an innkeeper's wife, aged forty-four, who has been ill for about ten weeks. There has been no insanity in her family, and she has three healthy children. When her husband was obliged to change his inn a little while ago, she began to complain of heaviness in her head, and worried herself groundlessly — e.g., with the idea that the children had no clothes, that everything was torn up, and that the house-moving would be the death of her. She thought she had made her husband unhappy, that the bailiffs were coming, that life was no longer possible at her home, and that every- thing was going to ruin. At the same time she spoke and ate but little, stared into space, and hardly slept at all. She also took a knife to bed with her at night, and expressed ideas of suicide, so she was brought to the hospital. Here she seemed quite collected and clear about her position, and, in answer to questions, gave a monosyllabic but consecutive account of her circumstances and her illness. For the last three months, she said, she had had no rest, and had been absent-minded and for- getful ; she had such a bad memory. She could not be happy now ; everything was spoiled for her, and her work had grown so hard for her that she could not get through with it. The patient spoke little of her own accord, and generally lay still in bed with a downcast expression. She was obliged to think for * The patient recovered without any distinct maniacal excitement, after having spent five months in the asylum, and gained 13 kilogrammes in weight. She has been well for six years since then. 2 1 8 Lectures on Clinical Psychiatry a disproportionately long time over the answers to simple ques- tions, was not quite clear about the chronological order of her experiences, and hardly knew at all where she was. All her expressions and movements were slow and hesitating, as if she did not quite know what she ought to say and do. She was low-spirited, and in particular cried a great deal when she had visitors. She described her complaint as *' dejection," and burst into tears whenever it was discussed, without being able to give a more precise account of her condition. The picture the patient now presents still shows substantially the same fea,tures : a quiet, oppressed mood, a sad expression, low, hesitating speech, and slow, tired movements, while at the same time she is quite collected. But the ideas of sin have grown much stronger. With tears, the patient calls herself the greatest of sinners, because she has brought her husband and children into misfortune ; she will certainly be executed. These are the same ideas of sin as we have learned to recognise in melan- cholia. We might, therefore, be tempted, especially in view of the patient's age, to take the illness for simple climacteric melan- cholia. But I think that this idea is contradicted by the obvious presence of the impediment of thought and will, which we have observed before, in just the same form, in maniacal-depressive insanity, but not in melancholia. I think that this symptom will justify our regarding the present case as one of the former disease. If this opinion of mine be correct, we need not expect a lingering, uniform course of disease, ending in recovery or in the characteristic state of weakness following melancholia, which has already been briefly described. We may hope for a much shorter duration of the disease, and for complete recovery, as the first attack of maniacal-depressive insanity generally runs a fairly rapid and favourable course. On the other hand, we must certainly be prepared to see it return, either as the same affection or in the form of excitement. The course of the case until now would certainly tend to show that we are right. The patient's downcast mood disappeared almost entirely after three or four weeks in the asylum. In its place she showed a rather impatient, discon- tented temper, with frequent smiling, of which we will learn the clinical meaning on a future occasion. The patient was so anxious to go home that her husband thought he ought to Stages of Maniacal-Depressive Insanity 19 humour her home-sickness, even against our advice. But her condition grew worse so quickly that she had to be brought back in four days. But probably we will soon effect an improvement even now.* The milder form of impediment of volition seen in this case is noticed by patients themselves as " inability to come to a decision," and meets us as such in the numberless mild cases of maniacal-depressive insanity which never come into an asylum, and, indeed, are never recognised as morbid states at all. Then we have the " psychological riddle," namely, that, without any adequate cause, but in the opinion of the sufferers and of those around them, as the result of some external influence, there arise times of complete inability to come to a decision, when every determination of the will costs the greatest effort, alternating more or less regularly with periods of the most reckless enter- prise. These mildest forms of the illness, leading by an infinity of gradations to the severe forms, and to the most severe, show how deeply maniacal-depressive insanity is rooted in the natural disposition of certain individuals. Hence we frequently find it in several members of the same family. Often enough we see nearly a whole lifetime filled with slight attacks, suc- ceeding one another almost uninterruptedly. But just as often the illness only appears a few times, as in the case described, either at a particular period of life, or as the result of some external influence. The attacks usually set in during the years of evolution, or later on at the time of reversion. Many of the quite slight attacks — which, by the way, may always alternate with the severe — pass off without any treat- ment. Other cases are sent as " neurasthenia " to different asylums and watering-places, or ordered to travel, and the patients then extol, with full conviction, the particular cure they were taking when the improvement or the change to excite- ment occurred. In all the more serious attacks, however, treat- ment in an asylum is urgently required, on account of the danger of suicide, which is greatest at the beginning or near the end of * Unfortunately, her husband again jeopardized her recovery by taking her home in the face of medical advice, and a serious attempt at suicide was the result. Rather more than a year later, pronounced hypomania took the place of the depression, making a short residence in the asylum again necessary. The patient has now been quite well for three years. 2 — 2 20 Lectures on Clinical Psychiatry an attack, because at those times their indecision does not make the patients incapable of pulling themselves together to act. In the asylum they must be carefully watched, and an intelligent and moderately strict treatment in bed should be carried out. Of drugs, bromides may be used, either alone or in combination with opium or other suitable hypnotics, but too much must not be expected of them. Prolonged warm baths sometimes do good service. Visits from near relations and premature dis- charge from the asylum are frequent causes of relapses. LECTURE III DEMENTIA PR^ECOX Gentlemen, — You have before you to-day a strongly-built and well -nourished man, aged twenty-one, who entered the hospital a few weeks ago. He sits quietly looking in front of him, and does not raise his eyes when he is spoken to, but evidently under- stands all our questions very well, for he answers quite relevantly, though slowly and often only after repeated questioning. From his brief remarks, made in a low tone, we gather that he thinks he is ill, without getting any more precise information about the nature of the illness and its symptoms. The patient attributes his malady to the onanism he has practised since he was ten years old. He thinks that he has thus incurred the guilt of a sin against the sixth commandment, has very much reduced his power of working, has made himself feel languid and miserable, and has become a hypochondriac. Thus, as the result of reading certain books, he imagined that he had a rupture and suffered from wasting of the spinal cord, neither of which was the case. He would not associate with his comrades any longer, because he thought they saw the results of his vice and made fun of him. The patient makes all these statements in an indifferent tone, without looking up or troubling about his surroundings. His expression betrays no emotion ; he only laughs for a moment now and then. There is occasional wrinkling of the forehead or facial spasm. Round the mouth and uose a fine, changing twitching is constantly observed. The patient gives us a correct account of his past experiences. His knowledge speaks for the high degree of his education ; indeed, he was ready to enter the University a year ago. He also knows where he is and how long he has been here, but he is onlj^ very imperfectly acquainted with the names of the people 2i 2 2 Lectures on Clinical Psychiatry round him, and says that he has never asked about them. He can only give a very meagre account of the general events of the last year. In answer to our questions, he declares that he is ready to remain in the hospital for the present. He would cer- tainly prefer it if he could enter a profession, but he cannot say what he would like to take up. No physical disturbances can be definitely made out, except exaggerated knee-jerks. At first sight, perhaps, the patient reminds you of the states of depression which we have learned to recognise in former lectures. But on closer examination you will easily understand that, in spite of certain isolated points of resemblance, we have to deal here with a disease having features of quite another kind. The patient makes his statements slowly and in monosyllables, not because his wish to answer meets with overpowering hin- drances, but because he feels no desire to speak at all. He certainly hears and understands what is said to him very well, but he does not take the trouble to attend to it. He pays no heed, and answers whatever occurs to him without thinking. No visible effort of the will is to be noticed. All his movements are languid and expressionless, but are made without hindrance or trouble. There is no sign of emotional dejection, such as one would expect from the nature of his talk, and the patient remains quite dull throughout, experiencing neither fear nor hope nor desires. He is not at all deeply affected by what goes on before him, although he understands it without actual difficulty. It is all the same to him who appears or disappears where he is, or who talks to him and takes care of him, and he does not even once ask their names. This peculiar and fundamental want of any strong feeling of the impressions of life, with unimpaired ability to understand and to remember, is really the diagnostic symptom of the disease we have before us. It becomes still plainer if we observe the patient for a time, and see that, in spite of his good education, he lies in bed for weeks and months, or sits about without feeling the slightest need of occupation. He broods, staring in front of him with expressionless features, over which a vacant smile occasionally plays, or at the best turns over the leaves of a book for a moment, apparently speechless, and not troubling about anything. Even when he has visitors, he sits without showing any interest, does not ask about what is happening at home, Jiardly even greets his parents, and goes back indifferently to Dementia Praecox 23 the ward. He can hardly be induced to write a letter, and says that he has nothing to write about. But he occasionally com- poses a letter to the doctor, expressing all kinds of distorted, half-formed ideas, with a peculiar and silly play on words, in very fair style, but with little connection. He begs for " a little more allegro in the treatment," and " liberationary movement with a view to the widening of the horizon," will " ergo extort some wit in lectures," and " nota bene for God's sake only does not wish to be combined with the club of the harmless." " Pro- fessional work is the balm of life." These scraps of writing, as well as his statements that he is pondering over the world or putting himself together a moral philosophy, leave no doubt that, besides the emotional barren- ness, there is also a high degree of weakness of judgment and flightiness, although the pure memory has suffered little, if at all. We have a mental and emotional infirmity to deal with, which reminds us only outwardly of the states of depression previously described. This infirmity is the incurable outcome of a very common history of disease, to which we will provisionally give the name of Dementia Prcecox. The development of the illness has been quite gradual. Our patient, whose parents suffered transitorily from "dejection," did not go to school till he was seven years old, as he was a delicate child and spoke badly, but when he did he learned quite well. He was considered to be a reserved and stubborn child. Having practised onanism at a very early age, he became more and more solitary in the last few years, and thought that he was laughed at by his brothers and sisters, and shut out from society because of his ugliness. For this reason he could not bear a looking-glass in his room. After passing the written examination on leaving school, a j/ear ago, he gave up the viva voce, because he could not work any longer. He cried a great deal, masturbated much, ran about aimlessly, played in a senseless way on the piano, and began to write observations " ' On the Nerve-play of Life,' which he cannot get on with." He was incapable of any kind of work, even physical, felt " done for," asked for a revolver, ate Swedish matches to destroy himself, and lost all affection for his family. From time to time he became excited and troublesome, and shouted out of the window at night. In the hospital, too, a state of excitement lasting for several days was observed, in which he chattered in a confused way, made faces, ran about at 24 Lectures on Clinical Psychiatry full speed, wrote disconnected scraps of composition, and crossed and recrossed them with flourishes and unmeaning combinations of letters. After this a state of tranquillity ensued, in which he could give absolutely no account of his extraordinary behaviour.* Besides the mental and emotional weakness, we meet with other very significant features in the case before us. The first of these is the silly, vacant laugh, which is constantly observed in dementia praecox. There is no joyous humour corresponding to this laugh ; indeed, some patients complain that they cannot help laughing, without feeling at all inclined to laugh. Other important symptoms are making faces or grimacing, and the fine muscular twitching in the face which is also very characteristic of dementia praecox. Then we must notice the tendency to peculiar, distorted turns of speech — senseless playing with syllables and words — as it often assumes very extraordinary forms in this disease. Lastly, I may call your attention to the fact that, when you offer him your hand, the patient does not grasp it, but only stretches his own hand out stiffly to meet it. Here we have the first sign of a disturbance which is often developed in dementia praecox in the most astounding way. As the illness developed quite gradually, it is hardly possible to fix on any particular point of time as the beginning. In such cases, the change which is taking place is easily referred to some culpable looseness of morality, which it is sought to combat by educational means. Onanism in particular, which is very common in our patients, is usually held to be the source of the disease, so that cases of this kind were formerly spoken of as the insanity of onanism. I am nevertheless inclined to see in onanism a symptom, rather than the cause, of the disease. We often see the whole severe mental and physical condition arise, without any striking degree of onanism, and we also know de- generate onanists who present quite different symptoms. Hence there cannot well be any question of a regular causal connection between onanism and dementia prascox. Besides, the disease is just as common among women, in whom the weakening effect of onanism must be much slighter. Lastly, it is to be observed that the disease often sets in quite suddenly, another circumstance not exactly adapted to confirm the supposition of its onanistic origin. * The patient afterwards returned to the care of his family unchanged. He has now been in an asylum again for three and a half years, dull and demented. Dementia Prascox 25 Dementia praecox often begins with a state of depression, which at first may easily be confused with the kinds of depression already described. As an example of this, I will show you a day-labourer, aged twenty-two, who first came into the hospital three years ago. He belongs, it is said, to a healthy family, and did well at school. A few weeks before his admission he had some attacks of apprehension, and then became disturbed, ill- balanced and absent-minded, stared in front of him, spoke in a confused way, and expressed vague ideas of sin and persecution. On admission, he gave hesitating, broken answers, did sums and obeyed orders, but did not know where he was. He hardly spoke at all of his own accord, or at most muttered a few almost in- comprehensible words : there was war ; he could not eat, lived by the word of God ; there was a raven at the window that wished to eat his flesh, and so on. Although he understood what was said to him quite well, and even let his attention be easily diverted, he did not trouble at all about his surroundings, had no desire to make himself clear about his position, and expressed neither apprehension nor desires. He generally lay in bed with a rigid, vacant expression, but often got up to kneel down or go about slowly. All his movements showed a certain constraint and want of freedom. His limbs remained for some time in the position in which you placed them. If you raised your arms quickly in front of him, he imitated the movement, and he also clapped his hands when it was done before him. These pheno- mena, called respectively flexibilitas cerea, "waxen flexibility," or catalepsy in the one case, and echopraxis in the other, are familiar to us from experiments in hypnotism. They are always symptoms of a peculiar disturbance of volition, of which we include the various manifestations under the name of automatic obedience. Inequality of the pupils is also to be noticed in our patient, and I must mention the occurrence of an attack of un- consciousness, with twitching in the arms. The patient's condition improved in the course of the next few months. He became clearer, his behaviour was more natural, and he had a distinct feeling of illness, but he remained strikingly dull, apathetic, and devoid of ideas. Nevertheless, he found employment outside, and only came back to the hospital a year ago. He had thrown himself in front of a train, losing his right foot and breaking his left arm. This time he was collected and clear about his surroundings, and showed considerable knowledge 26 Lectures on Clinical Psychiatry of geography and arithmetic, but spoke to none of his own accord, and lay in bed dully, with a vacant expression, without occupying himself or paying attention to what went on around him. He alleged as the reason for his attempted suicide that he was ill ; his brain had burst out a year before. Since then he could not think by himself ; others knew his thoughts, spoke about them, and heard if he read the newspaper. The patient is still in the same condition to-day. He stares apathetically in front of him. does not glance round at his sur- roundings, although they are strange to him, and does not look up when he is spoken to. Yet it is possible to get a few relevant answers by questioning him urgently. He knows where he is, can tell the year and month and the names of the doctors, does simple sums, and can repeat the names of some towns and rivers, but at the same time he calls himself Wilhelm Rex, the son of the German Emperor. He does not worry about his position, and says he is willing to stay here, as his brain is injured and the veins are burst. The waxen flexibility and echopraxis can still be made out clearly. When told to give his hand, he stretches it out stiffly, without grasping. You will understand at once that we have a state of dementia* before us, in which the faculty of comprehension and the recol- lection of knowledge previously acquired are much less affected than the judgment, and especially than the emotional impulses and the acts of volition which stand in closest relation to those impulses. The disease thus delineated agrees to a great extent with the case which was last described, in spite of the different development of the illness. The complete loss of mental activity, and of interest in particular, and the failure of every impulse to energy, are such characteristic and fundamental indications that they give a very definite stamp to the condition in both cases. Together with the weakness of judgment, they are in- variable and permanent fundamental features of dementia praecox, accompanying the whole evolution of the disease. Compared with these, all other disturbances, however prominent they may be in individual cases, must be regarded as merely transitory, and therefore not absolutely diagnostic, features. This holds good, for instance, of delusions and hallucinations, which are very frequently present, but may be developed in very * The patient has now spent five years in a nursing asylum, and has become quite affected and demented. Dementia Praecox 27 different degrees or be altogether absent, or disappear, without the fundamental features of the disease or its course and issue being in any way affected. Yet we may consider it a rule that states of depression which are accompanied at the very beginning by vivid hallucinations or confused delusions usually form the prelude to dementia praecox. Fluctuations in spirits are always only of a fugitive kind in this disease, and therefore cannot be made use of for the diagnosis. At the very onset, indeed, we often observe states of lively apprehension or sad depression, but generally we can soon satisfy ourselves that the affections of the emotions really disappear very quickly, even when the external signs of them continue for some time longer. Looking at the strongly-built postman, aged thirty-five, who stands before you now, you will hardly believe that a few days ago this man not only tried to make away with himself, but also wished to persuade his wife to die with him. He had been cut down insensible from the water-pipe a few days before. The patient is pale, and his general nutrition is much impaired. He is quite collected, knows where he is, understands his position, and gives relevant and connected answers to questions. He says that he has been ill for five weeks. He suffered from head- aches, and thought that his comrades talked about little failings of which he had been guilty in former places. He heard someone say, " We'll catch you ; we'll pull your little shirt off." There was also a great deal that he did not understand ; there was telephoning into his ear. Then he hanged himself because of the voices. Later on he began to work again, but was still apprehen- sive. He was afraid he had passed false money and would go to prison for it, was confused in his head, and asked his wife to shoot herself with him, as she would be left in misfortune if he went to prison. He could not sleep or eat, and kept on reproaching him- self. He saw a head, of which he was afraid at first, on the ceiling ; then, with his eyes shut, he saw two tables, of which one was split, and on them a house with windows and an arch. The patient relates all these experiences smilingly and with an affected way of speaking. He gives no further thought to his attempted suicide, or to his having been brought to the asylum. He offers his hand in a stiff, spread-out way, shows well-marked catalepsy and echopraxis, which also takes the form of echolalia, when he repeats words shouted to him immediately, sometimes distorting them. For the fir.<=t part of his stay in the asylum 28 Lectures on Clinical Psychiatry he laj' in bed almost all day, often with his eyes closed and without moving, not even stirring when he was spoken to or even pricked with a needle. As he sometimes related, he heard voices which said all manner of things before him or called them to him. He told in a whisper how he had seen a blue heart up above, and behind it quivering sunshine and another blue heart, " a little woman's heart." He also saw flashes of lightning and a comet with a long tail. The sun rose on the \vrong side. It is also to be noticed that for the last few days the patient has suddenly refused to eat, without any cause, so that it has been necessary to feed him artificially. He declined the suggestion that he should write to his wife, on the ground that he had more important things to do. He did not wish for a visit from her : " it would really not be worth while." When told to show his tongue, he opened his mouth, but rolled back his tongue with all his strength against his soft palate. Once, for a short time, he suddenly became blindly violent against his surroundings, without being able to give any account of his reasons afterwards. The only physical symptom worth noticing is a great increase in the knee-jerks. It cannot have escaped you that the same fundamental symp- toms of emotional dulness, absence of independent impulses of the will, and increased susceptibility of the will to influence, which have already struck us in the cases previously described, are to be found again in this description. And there are just as many details, such as the hallucinations and the extraordinary way of giving the hand, to support the conclusion that the present case is also one of dementia prgecox, which we drew from the emotional dulness and the automatic obedience. Finally, we must take a number of disturbances, which we shall have to consider more exactly at the earliest opportunity — the patient's senseless resistance to receiving food, to showing his tongue, and to writing letters, and also his stuporose behaviour — in the same sense. We therefore come to the conclusion that in reality the case now before us most probably belongs to the same disease as the two cases previously described. In those cases, however, we had to deal with diseases of several years' standing, which had resulted in a condition of incurable mental infirmity. Experience shows that this is by far the most frequent result of dementia praecox. The importance of our diagnosis would therefore consist in this : that we are now able, Dementia Praecox 29 at the very beginning of the illness, to predict its resulting in a characteristic state of feebleness, in the same way as we arrived at certain probable conclusions about the further course of the disease in circular stupor. The prognosis, however, is really by no means simple. Whether dementia praecox is susceptible of a complete and permanent recovery answering to the strict demands of science is still very doubtful, if not impossible to decide. But improvements are not at all unusual, which in practice may be considered equivalent to cures. In these cases the patients suffer a certain impairment of their mental and emotional activity and of their power of action, and other slight remains of the symptoms of the disease may perhaps be recog- nised, yet they may be fully capable of filling their old place in simple relations. It is a more serious matter that in most of these cases the improvement is only temporary, and that such patients are in great danger of relapsing sooner or later, without any particular cause, and then generally suffer more serious injury from their illness. We had to record such an improvement in our second case, though it is true that it did not go very far. It was followed by a relapse. In the case of our third patient also we may hope for the disappearance of the present symptoms, but we must be prepared for their return in an even more serious form.* * The patient, having made an extraordinary recovery physically, but with no proper understanding of his ailment, was discharged from the asylum after he had been there for three months. He has now been at home for four years and nine months, apparently cured. LECTURE IV KATATONIC STUPOR Gentlemen, — The cases that I have to place before you to-day are peculiar. First of all, you see a servant-girl, aged twenty- four, upon whose features and frame traces of great emaciation can be plainly seen. In spite of this, the patient is in continual movement, going a few steps forwards, and then back again ; she plaits her hair, only to unloose it the next minute. On attempting to stop her movement, we meet with unexpectedly strong resistance ; if I place myself in front of her with my arms spread out in order to stop her, if she cannot push me on one side, she suddenly turns and slips through under my arms, so as to continue her way. If one takes firm hold of her, she distorts her usually rigid, expressionless features with deplorable weeping, that only ceases so soon as one lets her have her own way. We notice besides that she holds a crushed piece of bread spasmodically clasped in the fingers of the left hand, which she absolutely will not allow to be forced from her. The patient does not trouble in the least about her surroundings so long as you leave her alone. If you prick her in the forehead with a needle, she scarcely winces or turns away, and leaves the needle quietly sticking there without letting it disturb her restless, beast-of- prey-like wandering backwards and forwards. To questions she answers almost nothing, at the most shaking her head. But from time to time she wails : " O dear God ! O dear God ! O dear mother ! O dear mother !" always repeating uniformly the same phrases. If you try to grasp her hand she draws it away very suddenly, and at last, if she can no longer avoid you, begins to roll it up in her apron. Orders are of no use ; on the contrary, she resists in everything you try to do with her. But when she quickly hides her hand directly one speaks of taking 30 Katatonic Stupor 31 away the bread, it becomes evident that she understands what is happening around her. In this clinical picture two new symptoms of disease stand out with great clearness — namely, stereotypism and negativism. The first, a kind of instinctive inclination to purposeless repeti- tion of the same expressions of the will, shows itself in the un- tiring running backwards and forwards, in the lacing of the hands in the hair, in the holding fast the bit of bread, and in the uniform expressions of speech. The negativism, a senseless resistance against every outward influence, we recognise in the " mutacismus " — i.e., forced dumbness — as well as in the whole persistent obstinacy of the patient. In addition, these characteristics have come forward many times in very similar forms in her ordinary behaviour. For a long time the patient would take no nourishment, so that mechanical feeding had to be temporarily resorted to. It is true that she asked for water, " and cakes with it "; then, as soon as it was brought, would not take it. But now she lets her food stand beside her, and after a little time begins to swallow it greedily, but stops at once if you try to persuade her. Other- wise, she eats double and treble quantities, and also, very dex- terously and unscrupulously, takes food away from the other patients. There is little to be learnt from her broken sentences of what is passing in her mind. She certainly sometimes calls the doctor " Herr Doktor !" and knows the names of all the attendants, but appears to have delusions of all sorts, and prays that she may be able to stay one night longer. " Grant me yet one night before the many, many fires of the whole world, before the great Judgment Seat, before the many men." She was tormented by " scythes." " Let me go, the many heads and the many arms. Must I carry the whole world, the whole earth ?" Whether the patient really experienced lively dread it is hard to decide. Threats make no impression upon her. Sometimes she twists her usually rigid features into a slight smile. Of physical disturbances there are to be noticed increased excita- bility of the facials, very active knee-jerks, and a bluish-red discoloraticn of the hands and feet. So far as it is possible to form an opinion from these observa- tions, it would appear that the patient's comprehension is com- paratively little disturbed, while confused delusions and perhaps 32 Lectures on Clinical Psychiatry illusions persist. In the emotional province a certain fear exists, but it can scarcely be very active, while in the province of action we meet with the phenomena of stereotypism and negativism in their fullest development. This diseased condition, which is distinguished from all those we have previously considered by these last two prominent characteristics, is known as katatonic stupor. The term " stupor " serves here for a state bearing only a quite superficial resemblance to the circular stupor already described. Some thirty years ago a disease was described by Kahlbaiim as katatonia, or " insanity of rigidity," of which the most pro- minent symptom is a stiffness in the muscles, which would rnly be increased by outward interference. The disease should run through a series of different evolutions, and end at last in re- covery or dementia. In the main, Kahlbaum's long-contested description has proved to be right, although I have to assume that the descriptions of disease summed up by him as katatonia are only special forms of dementia praecox. At all events, in katatonia also, disturbances of the emotional province and of action control the condition, while comprehension and memory suffer little in proportion. But then we meet with the katatonic symptoms — negativism, stereotypism, more especially the auto- matic obedience already described, the strange behaviour, and the sudden onset of senseless impulses — in all gradations in the different forms of dementia praecox. Indications of the same kind were also present in the cases already discussed. In our present case the development of the disease goes back only about sixteen weeks. The patient has no heredity, and had always been quiet and respectable. Some months pre- viously she went into service, and there became ill. She left of? working, wept and groaned a great deal, sat mute, and did not sleep. Then she became apprehensive. Now she would be tortured : the murderers would come with scythes ; she sang songs from the hymn-book ; she clung to her mother, and smiled from time to time. Once she sprang out of the window, another time down from a tolerably high rock, but without seriously hurting herself. On admission to the hospital four weeks ago, she behaved frivolously, answered only to pressing interrogation, but then correctly. She was clear as to place and time, said herself that she was ill mentally, declared that she had heard voices that always scolded her the whole time they were speak- Katatonic Stupor 33 jng ; the Saviour had allowed her to fall. The recognition of colour and numbers was quickly made out, as well as the solu- tion of simple sums ; also, in contrast to the condition found in circular stupor, the movements showed no kind of impediment. The patient presented echolalia and catalepsy ; further, we were struck by the grimacing movements of the muscles of the mouth. Negativism made itself apparent, m that the patient, who had been led into the room resisting, when told to go would not leave, but held back, only to decide on going when told to remain. The stupor which you have before you is only a stage of the course of the disease in katatonia. Its beginning reminds us distinctly of the states that we discussed in our last lecture. In the same way the termination can be a similar one. Sometimes, however, the stupor passes imperceptibly into confirmed im- becility. The patients may perhaps become a little more manageable and active, but they still remain wanting in ideas, and dull and slow, and also retain permanently many of the prominent features of the disease — illusions, confused hallucina- tions, stereotypism in deportment and behaviour, negativism, and automatic obedience. The stupor, nevertheless, can also form the transition to states of quite other kinds, or it can dis- appear, only to reappear.* The next patient whom I will bring before you to-day is a merchant, aged twenty-six, who comes into the room under guidance, with closed eyes, hanging head, and shuffling gait, and at the earliest opportunity sinks limply into a chair. On being spoken to, his pale, expressionless features do not show any animation ; the patient does not reply to questions or obey •orders. If you stick a needle into his forehead or his nose, or touch the cornea, there follows at most a slight blinking or flush- ing, without any attempt at defence. But during this the patient quite unexpectedly breaks into a slight laugh. If you raise his arm in the air, it falls down as if palsied, and remains in the same position that it took accidentally. After much persuasion the patient at last opens his eyes ; he now also gives his hand, .advancing it by jerks with stiff angular movements, and re- * After ten months' residence at the asylum the patient was able to return to her family. She was physically healthy and capable of work, but wanting in ideas, unintelligent, dull and inaccessible, and still showed -affected movements. At home she works, but lives in seclusion, and .associates with no one. 34 Lectures on Clinical Psychiatry mains like that. If you bend his head back, he stays in this uncomfortable position, and his leg, which I have raised up, he also keeps stiffly stretched in the air. By degrees one succeeds in calling forth still further signs of automatic obedience. The patient raises his arms if anyone does it in front of him, and imitates pushing and turning movements, whirling his fists with great exactness and ^apidit5^ On the other hand, he does not utter a word, presses his lips together when he ought to show his tongue, cannot be induced to write, and apart from sudden, repeated grins, remains quite mute, but repeats some words shouted out loud to him with his mouth closed. He at once obeys the order to go. The characteristic disturbance of will that forms a mixture of automatic obedience and negativism is, above all, obvious in this patient also. In a quite inexplicable manner the patient allows himself on the one hand to be influenced without will of his own, while, again, on the other hand, he suppresses the natural impulse of the will or that introduced from without. This contrast is best illustrated by his mimicry of speech with his mouth shut. As the result of his negativism, the patient has not for a long time opened his mouth in trying to speak, but yet he cannot quite withstand the impulse to imitate what is said before him. From this we recognise clearly that negativism and automatic obedience are psychological, but not clinical, contrasts. Indeed, both disturbances not only come forward in- the same patients at the same time, but they also very easily change into one another, so that you are never quite sure whether at a given moment you will meet with the one or with the other in a given patient. Sometimes also, through various suggestive means, you can at once lead over the one into the other. As it would appear, both are only an expression of the fact that the control of that deliberation, conscious of an end, over the impulse of the will is lost, so that now impulse and counter- impulse of inner or outer origin determine irregularly the sub- sequent action. Thus, at least to a certain extent, one would understand that the patients, even if their deliberation is not affected in itself, involuntarily first follow that impulse which presents itself to them, only persistently to answer it in the most stubborn way with the counter-impulse, or to repeat some senseless action or other innumerable times, in every case without any regard for their own weal or woe. It is clear that Katatonic Stupor 35 such a loss of connection between thoughts and actions, which perhaps rests on the profound destruction of the sensory Hfe, must quite rob the action of that inner unity and logical accuracy which we regard as the issue of healthy mental personality. By this means, even in the slighter forms of dementia prgecox, the proceedings and behaviour of the patients keep up their incom- prehensibility and their confusing tendency to jump from one thing to another. No one defined colouring of mood is to be observed in our patient. On the contrary, he is completely dull emotionally, shows no interest in what goes on around him, not even on the visits of his nearest relations, in whom he shows no interest, and to whom he speaks not a word ; he has no wishes, and does not care about anything. At the same time it can be seen from his occasional utterances that he is clear as to his situation, knows the people about him, and takes in what one says to him. Here again we find the same grouping of the disturbances in the order in which we were able to place them in the cases of dementia praecox already discussed. This conception is also in accordance with the previous history of the patient. His father was temporarily insane, and could not on that account finish his college course. The patient him- self learnt with difficulty, after having struggled through typhus in his youth ; was easily excited, anxious, and inclined to hypo- chondriacal broodings. He fell ill six months ago. As the result of differences of opinion as to plans of marriage, he became anxious, believed himself to be mocked by everyone, was afraid of coming into contact with the public prosecutor, and finally, because he looked upon his life as threatened, sprang out of the window one night in his shirt, fracturing his os calcis. On admittance, the patient was decidedly dull ; he declared him- self quite ready to remain in the hospital, although he was not insane, but only suffered from delusions. He had thought he would be murdered ; everything appeared to him so changed ; voices spoke to him about all sorts of family affairs ; catalepsy, echolalia and echopraxis were very marked. There was no demonstration of physical disturbances except an old scar on the head and a newly-formed callus on the foot. In the further course of the illness the patient's want of judg- ment, as well as his emotional dulness, became more and more marked. He thought that the meat placed before him to eat 3—2 36 Lectures on Clinical Psychiatry was human flesh ; everything in the newspapers was about himself ; the assassination of the Empress of Austria and the Peace Conference had to do with him ; his mother wanted to murder him ; he was the worst man alive. The doctor he designated as the German Emperor, who had dyed his beard ; another gentleman as Christ — all in quite an indifferent tone of voice, without a trace of emotion. Sometimes he said senseless rhymes to himself — " Nem, bem, kem, dem, schem, rem " — over and over again, or he repeated this incomprehensible sentence : " One for all, and all for one, and two for all, and three for all, here and there everywhere, and ' Almightiness,' and ' Almighti- ness,' and ' Almightiness,' " and so on. Gradually he became more and more quiet, and gave up speaking and eating, hid himself under the bedclothes, took up extremely uncomfortable attitudes, and allowed the saliva to run out of his mouth ; he has only latterly become rather more active again. A whole series of disturbances recur here with which we are already familiar : the illusions, the strange hallucinations, the dulness, the refusal of food, the twaddling speech, with play on words and stereotyped repetition. Through other symptoms, such as the hiding, the strange attitudes, and the slobbering, which are likewise frequent in dementia praecox, the description of katatonic stupor becomes still more complete. As to the future course of the case, the same will hold good as in that of the first patient ; probably the disturbances, now so well defined, will gradually clear up, while a more or less high grade of mental enfeeblement may remain.* The woman, aged twenty-eight, whom I will now show you is perhaps calculated to give you an idea of the further develop- ment of these cases. The patient has no heredity, married seven years ago, and has had four children. Headache, loss of appetite, and depression appeared at the first confinement, but only for some months. The same slight disturbances were noticed after the subsequent confinements also, a new and graver symptom showing itself after the last. The patient gave up working, ideas of persecution made their appearance, and she thought someone wanted to kill her by poisoning her food. * The patient improved somewhat, but was twaddUng and imbecile. He gained 24 kilogrammes in weight, and was taken home into family custody. Later on he went to a nursing asylum, where he died after the whole illness had lasted five vears. Katatonic Stupor 37 She became indifferent, capricious, resistive, much reduced in physical health, and ate little. At the same time, she remained quite collected, and understood what was said to her. On admission, nine months after the last confinement, the patient was mentally inaccessible, discontented, and fretful ; desired to go home again at once ; gave no information as to her condition, because she said she was not ill, and could work ; did not trouble about her surroundings or employ herself. One gathered from her occasional utterances, as well as from her letters, which onl}^ contained in endless repetition the entreaty to be fetched away, that she was clear as to where she was ; she also did simple sums very slowly, but correctly. A test of her knowledge and memory was impossible, as she did not answer questions directed to that end. In any case, an extraordinary poverty of thought existed. Delusions were not prominent, except perhaps single complaints that she appears to have been sold, and that people were angry with her ; hallucinations were absent. In the emotional province, except for an irritable, peevish character, complete vacuity existed. The patient sat there apathetic and dull ; she allowed no emotion to be per- ceived either at the Christmas festival or with visitors, not saying a word to them, while she devoured greedily the sweet- meats they had brought with them. All attempts to get on friendly terms with her she met with obstinate resistance. She remained nearly always mute, frequently refused food, would not remain in bed at night, refused to work, would take no medicine, often made herself dirty, neglecting the calls of nature, and so on. As you may see, the patient now sits with bent head, holding herself crouched up. On being spoken to she does not look up, but now and then throws a furtive glance around her if anything striking occurs. On shaking hands she does not give her hand, and if you grasp it you feel the arm become rigid. If you raise her head, it immediately goes down again ; if you try to bend it down or to incline it sideways, it springs back again in the opposite direction ; if, however, you put her leg on a chair, the patient allows it to remain in this uncomfortable position, a sign that indications of catalepsy also exist, side by side with nega- tivism, which have occasionally been seen at other times. The features are rigid, like a mask ; the lips slightly stretched out like a snout, a sign which Kahlbaum has designated as " snout 38 Lectures on Clinical Psychiatry cramp." Sometimes also slight tremors are seen round the mouth. After urgent and repeated orders to get up, the patient begins to rise slowly and jerkily, only suddenly to sit down again. It can be seen clearly on this and on numberless other occasions how the original impulse subsequently becomes thwarted through a counter-impulse. The patient cannot be persuaded to write on the blackboard. Lastly, the lively ex- aggerations of the knee-jerJcs, the mechanical excitability of the facials, strong idio-muscular swellings on tapping the muscles, the somewhat puffy face and the extremely poor action of the heart, are also noteworthy. The diagnosis of katatonia, in face of the results of the examina- tion submitted to us, cannot be doubted. Probably it is already a question of a final stage of dementia, which is hardly now capable of more extensive improvement* — so, at least, the marked signs of a far-advanced mental weakness indicate. The long duration of the illness also points to the fact that we have no longer to deal with a fresh example of disease still in a state of fusion. It certainly appears, up till now, as if a certain improvement has occurred alter each separate attack of the disease, but yet on the whole a gradual downward progress of the malady has taken place. Finally, it is a very important experience that childbirth has always worked unfavourably. This corresponds entirely with our former observations, which frequently show us a connection of the disease in women with the process of reproduction. In such cases, the very great revolutions in the economy of the body probably play a signi- ficant causative part. * The patient remained for five years in an asylum, quite imbecile, mute, negative, afiected, at times excited, and died of phthisis. LECTURE V STATES OF DEPRESSION IN GENERAL PARALYSIS Gentlemen, — You will see at once that the man, aged forty, whom I am to bring before you to-day is suffering from depres- sion. This haggard-looking patient, very pale and ill-nourished, sits in a languid attitude, staring straight before him with a gloomy, listless air, and pays us no particular attention. He hardly even turns his head when spoken to, but he answers in a low voice and very laconically. He gives his age, and says that he was a commercial traveller, and that he is married and has two children living, while one has died of fits. He has been about a great deal. He was at Basle last, travelling, but only remembers the station and the porters there. He cannot recol- lect anything more. In answer to questions, he shows consider- able knowledge of history and geography, and does sums fairly well, but suddenly remarks, " I cannot understand at all where the whole world has gone — the five continents." And yet, he goes on, he used to know something of all the towns, but now there is absolutely nothing left of them. He says that his mar- riage is no connection ; there are no husband and no wife, and the children are mere phantoms — " That has no place in my brain." There is nothing left of himself but " this miserable skeleton." The asylum and the people here are the only remains of the whole world. " The whole glory was gone at a single blow," and that has been brought about by him. All this is said in a tired voice, without emotion, but he will not admit that his fancies are morbid. He knows the doctors, but says he is not ill. After the conclusions to which we have come in previous lectures, we cannot take the state of depression before us for melancholia. Such a diagnosis is excluded by the patient's 39 40 Lectures on Clinical Psychiatry comparative youth and the indifference with which he makes the most extraordinarily inconsistent assertions — a symptom alwa\'s indicating a certain amount of weakness of judgment. For the same reason — the absence of deep emotional feeling — he can hardly be suffering from maniacal-depressive insanity. There are no signs of impeded volition. He speaks very little and in a low tone, but evidently because he does not feel any need of opening his heart, and not because of an obstacle he cannot overcome. On the other hand, we are strongly reminded of cases of dementia praecox by the languid way in which the patient brings forward the most senseless delusions. But we cannot discover any of those remarkable disturbances of volition which generally give so peculiar a stamp to the picture of dementia praecox. The patient shows neither auto- matic obedience, negativism, nor stereotypism ; he does not grimace, and, though his movements are slow and weak, they are natural and unconstrained. But, as these symptoms are not necessarily present in dementia praecox, it would be difficult to make the correct distinction if the physical examination of the patient did not bring complete enlightenment. We see that not only is the right pupil more dilated than the left, but both are completely inactive to light, although the reaction to distance is maintained. The right facial nerve is paretic, and the labio- nasal folds are effaced. The tongue is put out with tremulous jerks, and the knee-jerks are exaggerated on both sides. The sense of touch is normal, but the patient feels no pain if you stick a needle through a fold of his skin when his attention has been diverted. His walk is rather unsteady, and he sways a little when he stands with his eyes shut. The evidence of physical disturbances of this kind makes it absolutely certain that our patient's mental weakness depends on that progressive disablement of the brain which is generally called Dementia Paralytica, or General Paralysis of the Insane. In this disease we find a peculiar feeble-mindedness, advancing to the most extreme degree, in conjunction with a number of gross disturbances of the brain and spinal cord, some of which we have already discovered in our patient. The reflex sluggishness of the pupils, the hypalgesia, and the chcinge in the knee reflexes, are particularly important. So also are certain disturbances of speech and writing, which can hardly be established in this case, with so-called paralytic attacks, and finally, towards the end of States of Depression in General Paralysis 41 the illness, palsy and contraction of the most diverse muscles of the body. Rather less common are palsy of the muscles of the eyes, atrophy of the optic nerve, and many other results of the widespread disturbances in the brain and spinal cord. The disease seems always to develop after syphilitic infection, and hardly ever before from ten to twenty years have elapsed. At any rate, with the experiences we now possess, we can hardly doubt that cases which are not of syphilitic origin are scarcely of the same kind as the rest of those observed. In the case of our present patient, such an attack took place twelve or fourteen years ago. At that time he was treated, for skin disease and an affection of the mouth, with blue ointment and iodide of potassium. Four years ago he suffered for a time from double vision, which soon disappeared, but returned a year ago. He had been irritable for two years, and in the last half- year there was loss of memory, particularly for the most recent events, and he slept badly. The actual outbreak of the disease followed the journey when he was finally taken into custody on account of his extraordinary behaviour. At home he expressed ideas of sin — that he had made false entries in his books and would be locked up, and was bringing ruin on his friends as well as him- self. In the hospital he presented very much the same symptoms about a year ago as he does now. He refused to eat because everything cost too much, thought he was not ill, and wanted to go home. It was noticed that he sometimes gave the year of his birth correctly and sometimes incorrectly. Weakness of the bladder was observed, besides the physical disturbances already mentioned. In four months the patient was let out on parole, and even began to occupy himself at home, but very soon he declared that his brain had been cleared out with a broom while he was here, and a funnel put in. As he was excited at the same time, and threatened his wife, he had to be brought back to the hospital after only a fortnight. General paralysis, in our experience, usually leads to death in the course of a few years. Now and then it may last for eight or ten years, or sometimes even longer, but the end generally comes in four or five, and often very much sooner. This shows the very great importance of a correct and early diagnosis of the disease. When once the diagnosis has been made, we can immediately form a reliable prognosis of the case in accordance with our clinical consideration of the patient. Our present 42 Lectures on Clinical Psychiatry patient will succumb to his illness within a fairly calculable time.* The second patient I should like to show you is a locksmith, aged thirty-eight. He has considerable difficulty in understand- ing what is said to him, but is quite willing to tell about his circumstances. A sister died of an " abscess in the head." He used to drink a good deal at one time. He married four years ago, and has three healthy children. Nine months ago he noticed that his memory was failing. He could not do his work properly, his sight grew bad, and he was irritable and did not get enough sleep. Speech became difficult, and on many days he could not speak at all. He had headaches, could not run as well as he did before, and became depressed. Even as he tells us this we see that he is very uncertain in his statement of time, cannot quickly recall and calculate relations of time, and does not notice his gross contradictions in this respect himself. He also makes great mistakes in doing simple sums, and often cannot give an answer at all. But his other school-knowledge is quite adequate to his degree of education. He makes very extraordinary assertions about his health. Clutching at his throat, he maintains that his throat is growing together, his larynx has stuck, his sexual parts are rotten, he has not had a stool for weeks. " I am done for, I have lied, ready, amen ! Lay me in the grave ; telegraph home for them to come ! I have sinned ; everything is rotten !" He says he will die, he has to spit so much ; his food does not go into his stomach ; he has millions in his stomach. All this is said in a peculiar singing tone, without any perceptible emotion. The depth of this patient's dementia is evident from his emotional dulness and the senseless nature of his delusions, com- pared with his coUectedness in other respects. Hence, of the diseases so far known to us, there would at first be a question of dementia praecox as well as of general paralysis. We will be inclined to decide for the latter possibility, when we take into account the dishirhance of memory, noticed by the patient him- self, and clearly seen in his statement of dates. But it is the physical examination which turns the scale. During the patient's narrative we had been struck by the indistinctness and difficulty of his enunciation, as well as by the monotonous pitch of voice which is often observed in paralytics. The patient seems to chew his words, without bringing out the separate * The patient died when the paralysis had lasted not quite four years. States of Depression in General Paralysis 43 letters clearly. This " lalling " pronunciation, and other forms of disturbance of speech, are sjonptoms commonly accompanying the growing disablement of the brain. Our patient's writing, too, is unsteady and hurried-looking. The long strokes in particular are not straight and smooth, but show little irregular bends. The pupils are equal, but very much contracted, and react only very slowly and imperfectly to light and distance. When he repeats difficult words after someone, the effort is accompanied by facial spasms. The tongue trembles strongly when it is put out, and the left labio-nasal fold is effaced. Unexpected pricks with a needle are not perceived with ordinary pain. The knee- jerks cannot be excited, and standing with the eyes shut produces very marked swaying. After these results of the examination, of which the disturb- ance of speech, the almost entire loss of reaction to light in the pupils, and the absence of knee-jerks are particularly important, the presence of general paralysis of the insane cannot be doubted. Moreover, a disturbance of the bladder, in the form of retention of urine, was repeatedly observed. As for the development of the disease, we have learned from his wife that even eighteen months ago this hard-working and temperate man lived in great seclusion, worried a great deal, was clumsy in thinking, and was apt to forget things. For four or five months he had thought that his throat was growing together, had become very sad, would not eat without much persuasion, and hardly spoke at all. From observation in the hospital, I may add that he was much excited from time to time, got out of bed a great deal, sat on the floor in his shirt, was obstinate, and all night long repeated rhythmical phrases quite devoid of sense — " Griiner Raser, grober Raser, bunter Kater, grober Aber, ewiger Raben, Raben haben, rother Kater, Bummel-raber, gelber Kater, der Rosen graben," and so on. As this kind of play on syllables also occurs in katatonic patients, it might make the distinction of the present condition from dementia praecox very difficult but for the appear- ance of physical disturbances. The same is true of the abrupt change from complete refusal of food to voracious eating, which we repeatedly noticed in the patient. The delusions generally took the direction already indicated. He was a little boy, " only so big," weighed only 12 pounds, had a chronic crisis in his stomach. He was also in high spirits occasionally, and had senseless ideas of grandeur. At such times he felt quite well, 44- Lectures on Clinical Psychiatry and wished to pay a visit to his sister. An attempt at discharging him failed, for he ran naked into the street after he went home.* This patient, too, has had syphilitic infection, and that thirteen or fourteen years ago, and has been through a mercurial cure on that account. This might perhaps have induced us to repeat the treatment, as was actually done in our first case by the doctor under whose care it came. Unfortunately, the experience of alienists in this matter is very uncertain at present. As an im- provement, which sometimes goes a long way, often takes place in cases of paralytic disturbance, without any interference at all, or through simple rest or keeping in bed, it is naturally very diffi- cult to come to a clear decision as to the efhcacy of any particular treatment. For this reason, many cases are reported in which a favourable effect is ascribed to treatment for syphilis. From my own experience, I must consider the usefulness of mercurial treatment very doubtful, and I have so often seen sudden loss of strength result from such measures in paralytic cases that I cannot find courage to recommend the remedy any longer. If one wished to set one's conscience at rest, one might confine one's self to the administration of iodide of potassium, which at any rate is harmless. It is only in the not very frequent cases where luetic s^Tnptoms are still present that the mercurial method may perhaps be appropriate. The inefficacy of treatment for syphilis in general paralysis is one of the most important reasons against the assumption that the latter disease is merely to be considered a syphilitic manifestation. The real nature of the subtle connection which undoubtedly exists does not appear to have been satisfactorily explained at present, but so far every- thing seems to show that general paralysis is not actually a s^'philitic disease, but an after-disease of syphilis — " a meta- syphilis," as Mohius has expressed it. General paralysis very often begins, as it has done in the cases described, with a state of depression, which may either change later en to symptoms of another kind, or may remain permanent. It is therefore very important to pay close attention to the peculiarities of this state of depression, so as not to be surprised by the unfavourable results. Many paralytics are regarded as melancholies at the beginning of their illness, if the physical signs are not much developed, or even merely as hypochondriacs or neurasthenics. But the almost invariable experience will * The patient died, a few months later, in a nursing asylum. States of Depression in General Paralysis 45 generally hold good that neurasthenia does not appear in other- wise healthy people without a definite and tangible cause, and that it usually disappears comparatively quickly with rest. It is also a very important sign that general paralytics are usually only imperfectly conscious of their real condition — their weakness of thought, their irritability, their emotional dulness, and the loss of their power of work— and that they complain of all kinds of extraordinary imaginary illnesses instead. In neurasthenics, on the other hand, we are usually able to discover only a few unimportant disturbances, although these few are very painfully perceived by the patients themselves. As a rule, this is specially clear with regard to the state of the memory. While the para- lytic may completely fail to notice little contradictions and uncertainties, and be surprised when they are pointed out, the neurasthenic complains of the constant failure of his memory, when there is nothing more the matter with him than the in- ability to impress names or figures on the mind, which is often met with within the limits of health. While we met with certain symptoms in both of the previous cases reminding us of katatonic disturbances, the pictures which I am now describing may also present a very close resemblance to states of circular depression. Here j^ou see a shopkeeper, aged thirty-nine, who did well at school, and afterwards acquired a good education abroad. He has greatly developed his business, which he has carried on by himself for the last six years. His father died of apoplexy, and his mother suffered from arterio- sclerosis, and one of his sisters from some cerebral affection. Six or seven months ago the patient complained of pains in his back, tiredness, loss of memory, and incapacity for work, and he let his books get into confusion. He became sleepless and depressed, his appetite was bad, and he suffered from consti- pation and difficulty in urination, was weak on his legs, spoke indistinctly, and was senselessly anxious to get up out of bed. He also expressed ideas of persecution, thinking that shots were fired into his rooms and that the house was being burned down. His doctor recommended his admission to the hospital to be treated for melancholia, which set in only a few weeks after the beginning of the disturbances. The patient, who lets himself be led into the room slowly and hesitatingly, with downcast eyes, is of average height and strongly built. He is rather ill-nourished and of a pale yellowish 46 Lectures on Clinical Psychiatry complexion, while his lips are slightly cyanotic. He hardly seems to notice the questions put to him, but after much encouragement his lips are seen to move a little, though the most that can be heard is a whispered " Yes " or "No." But gradually he becomes rather more active, and begins a sentence in a faltering voice, breaks off short, and then begins again, so that he can hardly be understood. " I think I have venereal disease," and " Is what I have done really so bad, then ?" are the only con- nected sentences he utters. He either does not obey our instruc- tions at all, or does so with feeble and languid movements, which often remain unfinished. He does not speak a word of his own accord, but sits motionless and apathetic, in an attitude of fatigue. At first sight this picture seems very like that of the circular stupor which I have already brought to your notice. We get the impression that there is a severe impediment of the will, which makes the patient unable to speak or act. Yet it must strike us that he is not really dejected and depressed, but decidedly dull and indifferent. He is quite uninterested in what goes on around him, and only shows signs of trying to answer when he has been repeatedly and emphatically questioned, while he soon sinks back into his original apathy when he is left alone. The few remarks which he does make show that he knows where he is, but that he understands his position very little in other respects, and is not at all anxious about his future. If we also take into consideration what we have learned, in his previous history, about loss of memory, difficult urination, and deterioration of speech, we must entertain very serious doubts, notwithstanding the ideas of sin and the impediment of the will, as to whether we have to deal with a condition of maniacal depressive insanity or not. The physical examination of the patient throws further light on the case. We see that the left side of the face, especially in its lower part, is more flabby and wanting in tone than the right, and that the left upper eyelid droops a little. It is difficult to examine the pupils, as both the eyeballs are in constant motion, presenting the symptom of nystagmus. We may also see that the right pupil is much contracted, while the left is larger, and that perhaps there is still a trace of reaction to a strong light in both. The tongue is inclined a little to the left, and is with- drawn jerkily. The knee-jerk is exaggerated, and ankle and foot clonus are present. A needle may be stuck into the back of the States of Depression in General Paralysis 47 patient's hand without his starting or showing pain. His inaccessibihty makes it a difficult matter to judge with any certainty of the quahty of his speech and writing. The muscles of his arms, and more especially of his legs, are extremely flabby. The pulse is small and slow, fifty-six to the minute, the breathing superficial, and the temperature extremely low — 96"8° F. All the observations made in the hospital are in full agreement with this picture. At the time of the patient's admission reaction to light was still well maintained in the right pupil, while it had already disappeared in the left. Serious disturbance of speech was perceptible at that time, with trembling and awk- wardness of movement, loss of strength, and unsteady gait. The patient was somewhat inaccessible, and was confused about time and place. He complained of violent pains in his head, and heard the voices of acquaintances outside inquiring after his health. Speaking with difficulty, he declared that he thought he had contracted venereal infection, had grown confused hi his head from contact with putrid flesh, and had ruined his business. He refused to show his tongue, saying that he had lost it through venereal disease. He said it seemed that he was charged with murder, which he was supposed to have committed in the Hartz mountains years before, although he had never been in the Hartz mountains. A transformation had taken place in his whole body ; he had looked quite young for the last two or three days. Later on, he said on the contrary that he had quite gone to pieces, and that he had been a well-built man before. He had had to take great quantities of quicksilver at the beginning of his illness, and that had poisoned him. After a temporary improvement in his general physical and mental condition, the patient soon sank deeper and deeper into the dull and apathetic condition in which you see him now. At times he was apprehensive, and for short periods was violently excited at night, and expressed ideas of sin and persecution. Voices reproached him with sexual immorality, traps were set for him, and slanders were spread abroad about his having masturbated. Poison was put into his food to stupefy him and make him crazy. With a great effort to speak, he begged that no more witnesses might be brought against him, and that he might not be made even more unhappy. At the same time he took absolutely no interest in his surroundings, expressed no wishes, soon forgot his intentions and experiences, and was 4? Lectures on Clinical Psychiatry easily diverted. He often refused to defaecate or urinate, and took a very insufficient amount of food. His weight, after increasing a little at first, fell about i8 kilograms in five months. His temperature fluctuated almost continuously a little above or below 96*8° F., occasionally falling to g$'6° F. This is a disturbance which is far from uncommon in general paralysis. In this picture of mental disease, not only the impediment of volition and the ideas of sin, but also the hypochondriacal fancies, would agree with the hypothesis of a state of circular depression, though the patient's idea that he looked younger than before might very well arouse a suspicion of general paralysis. But the emotional dulness, the disturbance of memory, the diverta- biiity and, above all, the physical disturbances leave no room for doubt as to the paralytic nature of the affection. We must therefore expect that, even if the patient may perhaps show some temporary improvement, he will succumb to progressive degeneration of the brain within a fairly calculable time.* Many of the ideas the patient expressed seemed to point to former syphilitic infection and mercurial treatment, but we have not been able to arrive at absolute certainty on this point. * After a further loss of weight, the patient, who had returned to the care of his family, died about sixteen months after the appearance of the first signs of disease. LECTURE VI EPILEPTIC INSANITY Gentlemen, — Looking at the strongly-built and well-nourished man, aged fifty-five, whom you have before you to-day, you will not see anything remarkable in his demeanour, except perhaps a certain listlessness in his manner. In all other respects he behaves quite as if he were sane. He greets me politely, sits down, and waits till he is spoken to. He gives a consecutive though only a brief account of his circumstances, knows where he is, and how long he has been here, can tell what day and year it is, and knows the people about him. When asked if he is ill, he begins to wail, saying that his head is so giddy, that he is " so tired of life, has had enough of life." It is all over with him ; he will never be well again, and does not want to live any longer ; he is sick of life. They ought to give him something to make an end of it, and then he would not be alive to-morrow. His head and his belly hurt, and his heart-water comes up, and besides that, though he is an old soldier, he is always being slighted, and is of less account than any young scamp. The good God ought to take him to Himself. He can eat nothing now. His temper during these pious ejaculations is peevish and irritable. He bursts out if you touch on unpleasant circum- stances of his life, such as his relations to his wife, but is easily quieted. After we have asked him many questions, he gives a rather garrulous sketch of his career, to the following effect : Our patient belongs to a healthy family, and was well himself until the campaign of 1870-71, when he was present at several battles. At the mention of this he brightens up a little. There are many incidents he can still relate, and he says that he was " as strapping a fellow as any." In February, 1871, he was very ill of typhus, and was sent home. He lay for nine weeks quite 49 4 50 Lectures on Clinical Psychiatry confused and delirious. He saw the tumult of battle, shot, and cried " Hurrah !" without knowing about it afterwards. This was followed by a palsy of the left side, also affecting the tongue and eye. It got better only very slowly. There was loss of sensation in the disabled parts, and sight was affected on the same side. After his recovery, he now and then had sudden fainting fits, after which he was depressed, unfit for work, and tired of life, and it was quite a fortnight before he felt well again. At such times he had vivid dreams about soldiering, often bit his tongue till it bled, and once fell out of bed and knocked in his front teeth. Another time he fell in the garden and broke the bridge of his nose. The depression came on a few days before these attacks. He knew nothing of what had happened afterwards. The attacks gradually grew worse, and here alcohol has played a part, although the patient says nothing about it. But ap- parentl3^ he could not take much, got greatly excited on a small quantity, and easily became violent, without knowing anything about it afterwards. As the result of this, he passed several times out of one asylum into another, and meanwhile his wife was unfaithful to him. When the question is put to him, he admits that he has drunk, especially during the attacks, " to- forget himself," as it made it easier. Once he attempted suicide by hanging, but only knows what he has been told about it. Attacks of weariness of life still come on about once a month, and last for several days. It comes " flying, as it were," and also disappears suddenly — "clears up." As a rule, these attacks, which the patient quite recognises as morbid — as his •' nerve complaint " — are accompanied by loss of appetite and a furred tongue. He connects them with the weather ; dull weather he cannot stand. The cause of his being brought to the asylum this time was an indecent assault on a little girl, three and a quarter years old, whom he had taken for a walk. In the morning of that day he had a fainting fit, and then drank a few tumblers of wine. Then, according to his own account, he lost his senses, and knew nothing at all of what he did, but was depressed for a week after and threatened suicide. Apart from these attacks, the patient shows a certain poverty of thought, but gets on well enough without any difficulty in simple situations, occupies himself of his own accord, and behaves in an orderly way. He is very fond of talking about Epileptic Insanity 51 his military exploits, which he ornaments with all kinds of par- ticulars, and likes to set himself in a favourable light as " an old soldier." His exaggerated self-esteem makes him look down on those around him ; he thinks he works better than any of the warders, and knows more than the gardener. He shows a certain ceremonious politeness. He never forgets to salute the doctor, however often he may see him in the course of the day, and expects to be' treated with proper respect in return. His talk, and still more the letters he writes to various acquaintances in better circumstances, to ask for a present, are garnished with a quantity of polite phrases and pious expressions, in which " The good God, who never forsakes a German, and least of all an old soldier," has a particularly prominent place. In the case before us, we have to deal with a kind of depres- sion differing in several essential particulars from all the forms we have as yet considered. The first of these are its sudden appearance and its short duration. It is there in the morning, when he wakes, as if it had " come flying," and disappears in a few days as suddenly as it came. But he has numerous attacks of this, recurring with considerable regularity, year in and year out. The disturbance is therefore markedly periodical, a cir- cumstance pointing to a deeper morbid foundation, of which the individual attacks must be the manifestation, since they are never preceded by any special cause. The road to the right interpretation is pointed out by the fainting fits, in which the patient has injured himself and bitten his tongue. These are undoubtedly signs of the disease called Epilepsy, of which the most important criterion, in my opinion, is the more or less regular return of the very transient symptoms. It is true that in this case we do not hear of actual convulsive seizures, but the patient's wife said years ago that he sometimes became quite rigid during the fainting fits, so that it was impos- sible to open his mouth. The depression used to be very closely connected with these fainting fits, beginning a short time before and lasting for a few days after them, while memory was very much clouded afterwards. Here there was evidently haziness of consciousness, such as is very often seen in connection with epileptic attacks. At the time of the patient's offence against decency there was the same depression and haziness of conscious- ness, or state of semi-consciousness, as such a condition is generally called, associated with a fainting fit. In the asylum, the de- 4—2 52 Lectures on Clinical Psychiatry pression has appeared quite independently, and without any marked loss of memory, in the form of attacks, but not of faint- ing fits. Perhaps the reason for this is that the patient has been completely deprived of alcohol, which usually and regularly aggravates the symptoms of epilepsy, and certainly did so in his case.* We learn from the case before us that these periodical attacks of depression, which we have seen connected with fainting fits and states of semi-consciousness, are to be regarded as manifes- tations of epilepsy. We may add, on the strength of repeated experience, that during these periods of depression compara- tively small quantities of alcohol may lead to very severe con- ditions of semi-consciousness. This is perhaps the more com- prehensible, because it may be seen from experiments that, in addition to the increased difficulty of comprehension, all the impulses of the will have more uncontrolled liberty during the depression. This loss of control finds expression in the peculiar clinical colouring of the condition— i.e., the irritable, peevish " wound-up " temper. Now, alcohol works in exactly the same direction, so that it must find a very favourable soil in such a condition for engendering states of excitement with more or less complete loss of consciousness. The cause of epileptic disturbances must undoubtedly be sought in permanent changes in the brain, usually congenital, or acquired in early youth. In the present case the typhoid affection of the brain seems to have brought on the illness, although there are no remains of it to be seen now. A causal connection with the setting in of epilepsy is also attributed to injuries to the head. I will show you now a workman, aged thirty, who was kicked on the forehead by a horse nine years ago in the course of his military service. At the time of the accident he was unconscious for half a day, and spent four weeks in hospital, but he got quite well again, except for fre- quent headaches, particularly in the region of the forehead. About five years later, as he was sitting at his joiner's bench, a sudden darkness came over his eyes. He lost consciousness, fell down, and felt very much depressed when he awoke again after a short time. He had a fresh attack a year later, and from that time onwards the attacks have gradually become * The patient has been for nine and a half years in a nursing asylum, practically in the same state. Epileptic Insanity 53 more and more frequent, till now they occur every three or four weeks. They are preceded by a feeling of being " electrified in his head," so thut he can lie down in good time. During the attacks there are twitchings of his whole body, lasting only a few minutes. His lips have often been quite raw afterwards, and once he passed urine involuntarily during an attack. Besides these convulsive seizures, slight and quickly-passing attacks of giddiness frequently occurred, and the patient also speaks of apprehensive, irritable ill-humour, which has recurred several times in the last six months. A feeling of ill-temper and uneasiness suddenly comes over him, without any cause, and he cannot help " puzzling over a thought he cannot grasp." Then an extraordinary irritability sets in, accompanied by severe headaches, driving him at the least occasion to furious abuse and threats, and even to actual violence. After a few hours or sometimes days, this condition is suddenly gone, and he does not imderstand how he can have got so much excited. Once or twice his recollection of what he has done during the attack has been far from clear. Indulgence in alcohol, however moderate, seems to have favoured the outbreak of the attacks. If the patient drank during the period of ill-humour, he was rather sleepy at first, but then became worse than before. We have had opportunities, while he has been in the hospital, of observing a considerable number of attacks of this ill-humour, appearing at irregular intervals of from a week to a fortnight. While the patient is usually friendly, manageable, and very quiet, at these times, generally early in the morning, when he got up, he seemed tired, monosyllabic, slightly dazed, and fretful, com- plained in a grumbling way about some trifle or other, and had headaches. Once he took part in a dispute between two fellow- patients, and could only be kept from violence with difficulty. If he was left to lie quietly in bed, as a rule he was free and in- telligent next daj^ and looked on the past ill-humour as morbid. " Every word I heard annoyed me. I have times when I am not irritable at all, and then again times when I get wild at every trifle." The physical examination of this strongly-built and well- nourished man, who willingly gives a full account of his condi- tion, and came here of his own accord, shows a slight thickening of the root of the nose, particularly on the right side. A de- pression may be felt running across over the nasal bone, and 54 Lectures on Clinical Psychiatry extending as far as the orbit of the right eye. The forehead is sensitive to tapping, particularly on the right side. The septum of the nose is bent to the right. Above, on the left, there is a swelling in the form of a fold between the side-wall and the septum. The left pupil is rather larger than the right. The fingers show fine tremors, and the knee reflexes are exaggerated. The agreement of this clinical picture with the last is very instructive. Here, too, we have fainting fits, convulsive seizures, attacks of giddiness, and the peculiar ill-humour which returns at short intervals without apparent cause. There is also the toxic effect of alcohol. But in the second case, which is milder, and has not lasted so long, the general changes in mental life — the narrowing of the horizon, the exaggerated self-esteem, and the tendency to phrases and pious saws — are not yet developed. The illness is definitely ascribed by the patient to the injury to his head, and he says that his irritability first came on at the time of the accident. It is remarkable that, in the asylum, an attack of ill-humour followed immediately on a minute examina- tion of the nose. The patient went directly afterwards to his wife, abused her without any cause, and turned her out of the house. He was sorry for what he had done by the evening, and begged her pardon. This occurrence would point to some con- nection between the injury to the nose and the patient's attacks. It seems strange that the disease should apparently have set in several years after the accident. But the patient's increased irritability is said to have been noticed by his relations immedi- ately after his discharge from military service, and the head- aches, which now regularly accompany the ill-humour, began very soon after the injury. We have therefore tried to obviate the ill-humour by painting the nose with cocaine solution as soon as it begins, but as the separate attacks last for so short a time in any case, it has not been possible to form a definite opinion as to the efficacy of the treatment. On the other hand, entire abstention from alcohol seems to have had a favourable effect both on the severity and on the frequency of the attacks.* Finally, I ought to tell you that a sister of our patient is insane, and his father has suffered from epilepsy. Even if the injury to his head has played a part in the development of his illness, * The patient is at the present time very intelUgent, and has worked in- dustriously for nine years in the factory, without requiring any treatment in the asylnm, but epileptic attacks, headaches, and depression still recur. Epileptic Insanity '^S we must not overlook the fact that he was probably predisposed to epilepsy. The two cases described have already shown the great diversity of epileptic manifestations. Besides the actual con- vulsive seizures, we have seen fainting fits, attacks of giddiness, states of semi-consciousness, and depression, or ill-humour. All these very different forms under which epilepsy may appear may be combined in the same case. Sometimes they immediately follow one another, and they all show the same fundamental characteristic of periodicity. Hence Sammt has already ex- pressed the opinion that these disturbances, while apparently so different, are only equivalent manifestations of one and the same state of disease, and that they can to some extent replace each other. He therefore proposed to give the name of " equivalents " to the numerous forms which the epileptic attack may take, to show that they are only various forms of the actual convulsive seizure characteristic of epilepsy. This view is at any rate so far correct that we are justified in regarding all the phenomena I have brought to your notice, and many others besides, as symptoms of epileptic disease. Where one of them has been undoubtedly observed, we generally see some of the remaining forms peculiar to the illness developed sooner or later. In any one case, the clinical evolution of a single equivalent may prevail, while others appear at longer intervals, and in a less marked form. In my opinion, only the frequent and entirely similar return of these disturbances, which all belong to one definite group of forms, without external cause is conclusive of the diagnosis. From this point of view, the convulsive seizures, on which the greatest stress is generally laid for the establishment of epilepsy, would form certainly a very important, and probably the most severe, symptom of the disease. But, under some circumstances, we will have to consider cases in which convulsive attacks have never made their appearance to be epileptic, if only one or more of the known equivalents have been identified with certainty as frequently and uniformly recurring. The next patient, a brewer aged thirty- two, who was brought here from prison, presents a very varied development of the attacks. Early in the morning, at about five o'clock, he was turned out of a public-house in a state of intoxication. He had made a great deal of noise, and when he was arrested by the police he screamed frantically, hit out all round him, and bit 56 Lectures on Clinical Psychiatry them. Although he maintained afterwards that he knew nothing about the whole affair, but had had his " attack," he was condemned to fourteen days' imprisonment, because his behaviour did not agree with Kraffi-Ebing's description of the epileptic seizure. Towards the end of his term of imprisonment, the patient suddenly became very much excited and very violent, screamed out that the devil was in the cell, smashed everything he could reach, and was then gagged and brought in a strait- jacket to the hospital. Here he gave a correct account of his personal circumstances, but was very much dazed and very clouded about his surroundings, and the events which had just taken place. He said he had seen his mother and the good God, had driven to heaven in a splendid coach, had heard singing, and had been very much frightened. At his clinical examina- tion he took the assistant for one of the angels, and myself for the " dear Father, who gives us things," and thought succes- sively that he was in Paradise, in hospital, and before the assize court. In the course of the next few days visions of beasts set in. He saw beetles, rats, and mice, and people without heads, v^ho hit him with whips, and heard military music. We will see later on that these last appearances were certainly to be referred to his abuse of alcohol. He became clear again in a few days, and at once recognised the visions of beasts as morbid, while it was not till ten days later that he could take a common- sense view of his experiences in heaven. As you may see, the thick-set, powerfully-built patient behaves naturally, and gives a connected, though very long-winded, account of his past history and present condition. The only physical indications worth noticing are the old scar of a bite on the tongue, and a certain sensitiveness to pressure on the nerve-trunks, which is certainly connected with his taste for alcohol. He tells us that he has suffered since he was eleven years old from the " falling sickness," which set in after scarlet fever. Sometimes the disease has appeared every day. It comes suddenly in his head ; then he knows nothing more, and falls down, as he has been told. That may last two or three hours ; afterwards he has rather a headache, and knows nothing about the syncopal attack. He also has slight attacks in which he just loses consciousness, and comes to himself again. That has often happened of late years, and has lasted a few minutes. He does not fall down in these attacks. His mood is joyous ; Epileptic Insanity 57 he hopes to be well again soon, and behaves in a good-natured, confiding way to the doctor. He does not trouble much about his future. He has drunk a good deal on account of his occupa- tion, and his life has been a very unsteady one. He has been punished several times for assaults and damage to property, committed in a state of great excitement. Once he was found at night in a strange courtyard, and, without saying a word, he gave several stabs with a knife to a married couple, who called him to account. He says that he knows absolutely nothing about this. Observation in the hospital showed a number of different signs and symptoms. First, we saw ordinary and very severe con- vulsive seizures, then simple fainting fits of short duration, then the quite slight and transitory defections of consciousness described by himself, usually called " petit mal." In the midst of a conversation he suddenly said : " Now it's coming ; now everything seems confused ; it's growing dark before my eyes." His expression was strained, he leaned against the wall, and stammered some incoherent words. Then after a few seconds he said : " There, now it's better ; now it's over." In connec- tion with the convulsions, either before or after them, attacks of rage occurred, with maniacal disturbance of consciousness, in which he mistook his surroundings, stormed recklessly, and hit out all round. It must have been such a condition which led to his last arrest. We know that in epileptics alcohol is particularly apt to bring on excitement of this kind with a dazed condition. This is the so-called " pathological state of intoxication." The periods of ill-humour, which have been very frequent in this patient, are to be regarded as the milder and mildest forms of the attacks. At these periods, though generally good- natured and contented, he grumbled and felt himself slighted, demanded to be let out soon, threatened to smash up everything, and occasionally was violent. After a few hours, or at the latest next day, he was friendly again, began at once to occupy himself industriously, and understood perfectly well that he had been ilL Lastly, peculiar delirious conditions also came under observation — " dreamings," as the patient called them. One night he thought he was in his married sister's house, and talked to his dead mother ; another time it seemed in the night as if his step-father gave him money. " All at once I thought, 58 Lectures on Clinical Psychiatry Good God ! where can I really be ? They can't have let me out of the asylum, and I can't have run away either. Where did I get the money ? And yet I mustn't drink !" The visit to heaven, which he thought he made when he was in the prison, must certainly also be supposed to belong to this group of symptoms, even if there was alcoholic delirium at the same time. I think that the difference comes out very clearly in the quicker correction of his ideas about the alcoholic visions. Perhaps it is also due to such delirious conditions that once, when the patient was at his work, he found himself standing up on the window-rail, without knowing how he had come there. Another time he was seen lying in bed, plucking at the counterpane with a monotonous movement, and murmuring in- comprehensibly to himself, apparently in a deeply stupefied condition. One or more of these attacks of various kinds occurred almost every day, generally several together in groups. The patient was treated with bromide of soda, but with hardly any result. The emplo}Tnent of opium in increasing doses up to 60 drops three times a day, with the sudden substitution of 12 grammes of the bromide, which has recently been recommended, was also without any good effect. It is possible, however, that the con- dition may still be improved to a certain extent by a very long continuation of the treatment with bromides in doses of from 4 to 6 grammes. Complete abstention from alcohol is a matter of course.* * The patient was transferred to a nursing asylum. LECTURE VII MANIACAL EXCITEMENT Gentlemen, — In the course of our lectures hitherto we have considered widely different states of depression. It has been my aim to show you that sad or apprehensive depression permits in itself of no conclusions as to the disease through which it is engendered. It is far more our task to become clear as to the special clinical meaning of this s^onptom in each separate case. Under some circumstances, we can draw important conclusions as to the nature of the underlying disease merely from the kind of depression, from its duration, from its repeated return, from its trifling depth, and so on ; but often enough it is the considera- tion of the other symptoms of disease that will first lead us on the right track. Very similar conditions can, at the first glance, be apparent in the course of very different diseases. But in- versely we frequently find that the most differentiated and appar- ently quite opposite conditions can make their appearance in succession as indications of the same malady. Here there is no question of the connection of different independent diseases, as was formerly often believed to be the case. Apart from the frequency of the phenomenon, this is proved to a certainty by the often extraordinarily rapid transition of the alternating pictures, by the occasional mixing of the separate features, and, lastly, by the similarity of the course and its termination. The powerfully-built and well-nourished merchant, aged fifty, who is brought before you to-day, enters the room with a rapid step, and greets us in a loud voice ; he takes a seat with a courteous bow, and looks about him expectantly and with curiosity. He answers quickly and with assurance as soon as we address him, and gives fluent and pertinent information as to his personal circumstances, as well as 59 6o Lectures on Clinical Psychiatry concerning his present position. Very soon he not only answers, but also leads the conversation ; says jokingly that he is not going to relate everything so glibly, but will make the examination a little more difficult, in order that he may see whether we under- stand anything ourselves. He explains that he suffers from paralysis, makes quite senseless statements, and adds up in- correctly, but is as happy as a king if you go further into things. If you give him free scope, he talks a great deal and with anima- tion, hardly allowing himself to be interrupted ; but he easily loses the thread, forever bringing into his history some new irrelevant details. A short, concise answer cannot be obtained from him ; he has alwaj's something to add and to exaggerate. During my lecture he, at intervals, frequently asks for " a hearing," but always draws back with a polite bow. He often addresses his discourse to j-ou students, adverts to student life, interpolates verses from student songs, even making up some topical doggerel rhjTnes himself. His frame of mind is joyous and exalted ; he amuses himself with all sorts of jokes, even tolerably risky ones, makes fun of himself and of others, imitates well-known characters, laughs at his own tricks, which he knows how to put in quite a harmless light. For instance, the last few nights before his admission to the hospital he had gadded about to all sorts of taverns and disreputable houses, had drunk hard everywhere, behaved in the highest degree extravagantly, sprinkled himself from head to foot with water in the market-place, and had driven in a cab from one public-house to another in the neighbouring villages. Finally he smashed the mirror, crockery, and furniture in his own house, so that he had to be brought to the hospital under a strong escort of police. For all that, he observes cutely his wife alone is to blame, for she did not treat him properly, nor had she cooked anything decently for him. As a consequence, he had to go to the public-house, and, besides, he must give people something by which to earn a living. He does not consider himself to be ill, but, he adds with a significant smile, if it will give us pleasure, he will remain with us awhile. The patient does not present any physical disturbance, except some wounds that he sus- tained in being conveyed by force to the hospital. This case appears to us in every respect to be the exact opposite to certain states of depression that we have already learnt to recognise. Comprehension occurs quickly, ideas spring up Maniacal Excitement 6i unhindered, though soon driven out by something new. The spirits are cheerful, actions run untrammelled and without ob- stacles, without even those which act as a restraint in normal life. This combination of symptoms of disease, which we fre- quently meet with in the same form, we designate by the name of Mania, or, if the individual disturbances are only slightly developed, as in the present case, by that of Hypomania. Our patient is, however, by no means always so considerate and jovially amiable as he is at present. For a time, especially at the beginning, he was quite confused and incoherent in his headlong talk, very irritated by his surroundings, smashed tables, chairs, and window-panes, poured his soup over his head, and behaved in very disgusting ways. At other times, by teasing and ill-treating the other patients, slandering the attendants, and grumbling and making mischief at every opportunity, he was almost unbearable. Mania, to a certain degree, is not only a true subversion of states of circular depression, but in itself is nothing but a stage of maniacal-depressive insanity. Where we really meet with maniacal excitements we are then able to draw the probable inference, not only that the excitements will recur often during life, but that states of depression of the kind already described will alternate with them. To return to our patient, we can state that he has already been in the asylum seven times. He is illegitimate ; his mother died of an apoplectic fit ; a sister of hers was insane. The patient had always been considered eccentric, but was sober and industrious. The first attack of the malady occurred in his thirty-seventh year, and exactly re- sembled the present one. At that time the patient, through the press, suddenly invited the whole " nobility of the place " to a " haute-volee soiree " at a belvedere, drove up to the police- station with the pretext that he had discovered a long-wanted anarchist criminal in the person of a gendarme, and indulged in all manner of practical jokes with the officials. He was at that time supposed to be suffering from general paralysis. The later attacks began with an inclination, for the time being, to extrava- gant expenditure, alcoholic and sexual excess, as well as every imaginable open misdemeanour ; once on admission to the hos- pital he had all his pockets full of worthless rings, foreign coins, and cheap jewellery, which he had bought up everywhere, as well as numerous pawn- tickets. 62 Lectures on Clinical Psychiatry At the beginning the attacks lasted from two to three months, and later on about six months. The patient generally soon became composed in the hospital, and scarcely presented even slight disturbances, yet a number of experiments of dismissal turned out badly because he at once began to drink again, and then quickly became re-excited. After recovery, he was, in the intervals, a very sober man, leading an extremely retired life, and on good terms with his wife, whom he tormented and insulted in his excitement. For three months after the last dismissal but one, and for nine months after the last, he was deeply depressed, misanthropic, lay in bed a great deal, and expressed thoughts of suicide, until his mental equilibrium gradually became restored. The expectation already expressed by us has been verified. Not only have a series of maniacal attacks occurred, but in the course of the year attacks of depression with distinctive features have also made their appearance. Most probably the future will bring a more or less regular return of one or the other of these states.* That in the course of time the duration and severity of the attacks have increased, while the intervals have become shorter and shorter, corresponds with the general experience of the disease. The future course will probably involve a gradual aggravation of the behaviour of the attacks, with fluctuations possibly. As you may already have guessed from the noise outside, the second patient, who now storms into the room, is violently excited. She does not sit down, but walks about quickly, examines briefly what she sees, interferes unceremoniously with the students, and tries to be familiar with them. No sooner is she induced to sit down than she quickly springs up again, flings away her shoes, unties her apron, and begins to sing and dance. The next minute she stops, claps her hands, goes to the black- board, seizes the chalk, and begins to write her name, but ends with a gigantic flourish which in an instant covers the whole board. She wipes it off perfunctorily with the sponge, again hastily writes some letters of the alphabet, suddenly flings away * After the setting in of tranquillity the patient was at first low-spirited for a long time, and a year later he again became maniacal. This time severe epileptiform attacks set in, with subsequent appearances of loss of power, in one of which the patient succumbed. The post-mortem showed widespread arterio-sclerosis of the bloodvessels of the brain. This termination appears to be not altogether unusual in maniacal- depressive insanity. Maniacal Excitement 63 the chalk over the heads of the audience, seizes the chair, swings it in a circle, and sits down on it with vigour, only to spring up again immediately and repeat her pranks in other forms. During the whole time the patient chatters almost incessantly, though the purport of her rapid headlong talk is scarcely intelli- gible and quite disconnected. On addressing her impressively, one generally obtains a short, sensible answer, to which all kinds of disconnected sentences are, however, immediately joined. Still, one can sometimes follow up her erratic thoughts ; they seem to be recollections springing up, fragments of phrases and verses, words and turns that she has heard formerly from her companions, and which she now interlaces into her stream of talk. The patient gives her age and her name, and knows that she is in a " mad-house," but gives quite arbitrary names to other people. She refuses to be led into a connected conversation, but at once digresses, jumps up, addresses one of the students, runs to the window, sings part of a song, and dances about. Her mood is extremely merry ; she laughs and titters continuously between her talk, but easily becomes angry on slight provocation, and then breaks out into a torrent of the nastiest abuse, only to become tranquil a minute after with a happy laugh. In spite of her great restlessness, she is tolerably easy to manage, and obeys orders given in a friendly tone, although it must be admitted that she immediately does something else quite different. There is nothing to notice in the physical condition of the delicately-built patient, except a certain amount of anaemia, and an inflammation of the margin of the left eyelid, which she will not allow to be touched. The extraordinary mutability of the individual psychical ■processes constitutes the characteristic feature of the condition under consideration. These processes are quickly and easily induced, but just as easily supplanted by others. Some acci- dental attraction at once arrests the attention, but only for the moment ; every arising idea or mood, every impulse of the will, is already replaced by another before it is properly carried out. Evidently the patient is wanting in ability to prevent herself from being ruled in thought, mood, and action by the changing influences of the moment, or to work these out to their proper endings. It is in this way that the important symptom of divertibility arises — that is to say, increased liability to influence through outward and inward attractions. In the province of 64 Lectures on Clinical Psychiatry comprehension it makes itself perceptible in that it is not impres- sions of real importance that arrest the attention, but those which, presenting themselves directly, are chosen at haphazard, to be at once replaced, just as accidentally, by others. Thus, in the province of the course of ideas, there arises that phenomenon which we are accustomed to call the " flight of ideas." As the idea of a goal is wanting which gives its fixed direction to healthy thought and at once arrests all side issues, the train of thought is perpetually driven out of its course, while incidental and non- essential ideas, often only awakened through habit of speech or similarity of sound, intrude everywhere. That the succession of thought is not hastened by this, as is generally taken for granted, but that the generation of new ideas often goes on very inadequately and slowly, can easily be proved by suitable experi- ments. But the designation " flight of ideas " is so far quite appropriate, as, in point of fact, the duration of the individual idea appears to be very much shortened ; the ideas are " fleeting," and soon fade again before they have actually attained clearness. Hence, as a rule, there exists at the height of such disturbance a more or less pronounced incomplete consciousness. The divertibility can be recognised in the abrupt change of colouring of the frame of mind, which can change in a moment from exuberant merriment to angry irritation, as well as to tearful despair. Lastly, in the form taken by expressions of the will, the disturbance shows as motor unrest, as press of occupation. There constantly spring up in the patient the most manifold impulses of the will, whose transposition into action is impeded by no checks, but is very soon crossed by new impulses. Compare this description with the picture of the first patient, and you will easily see that there we were met by the same features that meet us here, only they were in a less aggravated form. There, too, we noticed the divertibility of the train of thought, the change of mood, and the unsteadiness of the will, and the tendency to give way unresistingly to every rising im- pulse. In both cases we have in reality the same picture of disease, that of maniacal excitement. That the differences, so striking at the first glance, are only a question of degree, becomes clear to us when we see the same state develop with growing excitement in the first patient as in the case we are now con- sidering. But, again, our patient has from time to time presented the picture of " hypomania." Certainly that is not true of the Maniacal Excitement 65 present attack, which began pretty suddenly about two months ago or at least is only true of the first few days. On the other hand, as we had to consider probable after our previous lecture, the patient has already gone through a whole series of maniacal attacks, some of which have passed off wonderfully mildly. The woman is now thirty-two years of age ; her father was very excitable ; so also was his brother, who committed suicide ; and a cousin of the father was insane. Her sister is feeble- minded. The patient's illness began in her fourteenth year with an attack of depression, which was followed two years after by a state of excitement. Two years later another attack of depres- sion came on, with self-accusations and severe impediment of the will. This was followed by an excitement, then again by a depression, and then another excitement. From that time fre- quent fluctuations between slight depression and hypomaniacal states were observed, but were only recognised as morbid by the mother. The patient led, at that time, an unsettled life, pub- lished a notification of marriage, engaged in love affairs without discretion, which were not without results, but had only been considered by her friends as " full of spirits." Once she actually married while in such a state, only to separate again. Thrice the excitement was so strong that the patient had to be tempo- rarily lodged in an asylum. In her states of depression she felt deep repentance for her behaviour during the excitement Between the attacks long periods intervened, however, in which neither sad nor cheerful moods existed. The whole development and course of this case is wonderfully diagnostic of maniacal-depressive insanity. The beginning at a youthful age with depressed states of mind, the later vacillation between mania and depression, the occurrence of a single severe attack after numerous slighter ones, which to the uninitiated scarcely appear as morbid, we find repeated in the same way innumerable times. We know from experience that patients of that kind are generally descended from families in which attacks of mental derangement have occurred. We may expect that our patient will have a series of different-coloured mild or severe attacks to go through in the future.* * After five months' duration of the attack the patient recovered, -wdth great increase of weight, but in the twelve years elapsing since then she has again been through numerous slight depressions and excitements. Meanwhile her daughter has twice suffered from mania, the first time at iifteen and a half vears of age. 5 66 Lectures on Clinical Psychiatry ,Our next patient, a sea-captain, aged forty-nine, also begins to speak immediately on his entrance, and introduces himself as " The accused under chief command of Herr Professor General K." He answers the questions put to him promptly, and shows that he is quite clear as to time, residence, and sur- roundings. Very soon, however, he goes into long-winded, nineteen-to-the-dozen statements, which he suddenly brings to an end with the somewhat surprising remark, " Either I am well or ill or off my head." To the name Katherine he adds " Kath- reinen-Kneipps-Malzkaffee " — " Frohlich Pfalz, Gott erhalts " (" Happy Palace, God uphold it !")— " all will be roasted." His comprehension and memory are very good ; he makes his state- ment with a kind of joking minuteness ; he came to the hospital on Friday, July i, at ten minutes to six o'clock. He considers himself well ; there was no need to bring him here. He makes derisive remarks about the doctors and the hospital, as well as about himself; he may talk nonsense, but he is clever — more clever than the doctors, who learnt nothing in Heidelberg. When he begins to " thee and thou " us, and we express our astonish- ment, he breaks out into a torrent of abuse, trying always to surpass himself, and ending in shouts of laughter. His mood is exalted and insolent, his behaviour jolly and vigorous ; in answering, he holds his hand to his temple as in military salute, speaks loudly and abruptly as if making a military report, but soon relapses into the easy tone of a narrator. The patient's real condition, as you will have already seen, is likewise one of maniacal excitement. The unstable nature of his- train of thought, the exalted, changing mood, the motor un- rest, and especially the passion for talk, are significant enough. You would also be astonished at his press of occupation in other ways if you saw him in the ward arranging his clothes in ever nevv^ and intricate fashions, manufacturing a horse out of his bedding, on which he rides, or an anchor, the emblem of his calling ; how he bawls, dances, or sings, and also occasionally destroys what he gets hold of. Our previous conjecture, based on common experience, that the present attack was certainly not the first, proves to be true. The patient came here for the first time eight years ago ; since then he has been here eight times. The attacks set in each time quite suddenly — the two first after a fall into the water, the second at the burial of his daughter, the later ones without known cause. Each time he at once became Maniacal Excitement 67 very excited, and developed the most senseless delusions — that he was God, Joseph in Egypt, called his companions by the names of princes and emperors, and had to be put into a strait- waistcoat on account of his very violent resistance. The excite- ment disappeared regularly, however, after from one to two weeks, so that he could soon be let out again. The last five admissions took place this year. For this reason we kept the patient in the hospital this time after the disappear- ance of the excitement, and during that time we were able to observe the beginning of two new attacks. We have tried to cut short the last attack by at once giving the patient 12 and then 15 grammes of bromide of sodium daily on the first symptoms of excitement. In point of fact, the attack passed off much more quickly and mildly than the previous ones ; perhaps we might venture to hope that the next attack will be longer in coming.* In addition to this, we have employed those remedies which are generally found to be of use in maniacal states — first, rest in bed ; but when that was found impracticable, then prolonged warm baths, which we are accustomed, under certain circum- stances, to employ, with the best results, for a month at a time, for the half or even for the whole of the day. Doses of hyoscin or sulphonal are often necessary at the commencement to ac- custom the patients to the baths ; but afterwards they stay in the comfortable warm bath, in which they also take their meals and can sometimes amuse and occupy themselves, without much resistance. As in this case, it is found that with many patients simple separation from others is an efficient calmative, the em- ployment of which has, however, to be immediately abandoned if and so long as the patients show any inclination to uncleanli- ness or destruction. Under kindly, quiet, non-exciting treat- ment, these " delirious " patients are far less troublesome than one usually imagines. So far we have only considered the states of excitement in our patients. As they generally come under observation, morbid phenomena of that kind are commonly designated simply as " periodic mania." Very marked low spirits have, however, * After a very brief excitement four weeks later, also treated with bromide of sodium, the patient remained well for over five months, then had another slight relapse. Two years later two new attacks followed with a short interval, the last as the result of the death of his wife. The patient has now been well for two years. 5—2 68 Lectures on Clinical Psychiatry been also observed here. Especially after the disappearance of the excitement the patient was often downcast and quiet for days, thought that he had no longer any friends left — it was misery to be in his position. There are also hours intervening in the mani- acal excitement when he weeps bitterly and deplores his sad fate, soon to fall back into the old boisterous mood. It appears to me that not only the deep inward relationship of such apparently contradictory states, but also the clinical unity of all those cases, which one generally tries to distinguish as the different forms of simple and periodic mania and of circular insanity, are distinctly marked in these fluctuations, which are hardly ever absent, even in the most hilarious mania. The tendency to repeated relapses, as well as the usually favourable termination of a single attack, is common to all of them, even if the indications are very severe and of very long duration. LECTURE VIII MIXED CONDITIONS OF MANIACAL-DEPRESSIVE INSANITY Gentlemen, — If the different colouring, severity, and duration of even a single attack of maniacal-depressive insanity can give an extraordinarily varied form to the pictures of disease, this wealth of form will receive yet a substantial increase through the consideration of some further cases. The woman, aged thirty-eight, now led somewhat resisting into the room presents a very striking appearance. She is haggard, badly nourished, and pallid. The wrinkled face, prematurely aged, has a sullen, peevish expression. Her head is somewhat bent forward, her gloomy eyes slowly wander round the hall. Upon her dishevelled, short-cropped hair she wears a wonderful wreath of leaves entwined with threads of bright wool and scraps of paper. Her wrist is adorned with a strip of stuff torn off a coverlet. Threads are twisted round some of her fingers. The left hand is pressed to her bosom, and clasps a bunch of leaves and a folded handker- chief. The patient advances slowly and with hesitation, and sits down on urgent persuasion. She makes no reply at all to the questions put to her, but every now and then one hears a low incomprehensible muttering. Her attitude is constrained, but a certain amount of unrest is to be seen in the slight move- ments of her fingers. She carries out simple orders, such as to get up, to give her hand, and to show her tongue. She goes to the table, opens a little drawer for the chalk, and examines it, muttering to herself. Then she goes to the door and wants to go out, but lets herself be brought back again without difficulty. She shrinks back frightened on her hand being pricked with a needle, and pulls it out of the skin quickly, throws it away, and rubs the painful spot. On being told to write her maiden name on a sheet of paper handed to her, she dashes it off, her face 69 70 Lectures on Clinical Psychiatry lighting up with a grin of pleasure. Suddenly she takes off her shoe, and also attempts to rid the assistant of his ; then she raises herself up again, and goes from one to another of the audience, trying to take away some of their possessions that please her, whispering under her breath, " Give it to me ; I want that, I want that." Then she tries to take possession of some of the coats and hats that are hanging up, only allowing them to be taken from her with some trouble, scolding to herself in an undertone, and vigorously resisting being led out. The clinical signification of this condition offers considerable difficulties. Evidently we have to deal with a form of stupor. The patient understands correctly the simple orders given to her, but has the most hazy comprehension of her whole position, and it is out of her power to give any connected information what- ever. All her expressions of will are inadequate and aimless. So far we have met with states of stupor chiefly in katatonia and circular depression ; they also occur in epilepsy, hysteria, and paralysis. The physical examination, in which no noteworthy deviations are to be found, supplies no support for the assumption of paralysis. Epileptic or more especially hysterical stupor might perhaps occur to one, but that supposition at once becomes untenable when we learn that this condition has lasted two years and four months essentially unchanged. Katatonic stupor could very easily be as prolonged, but precisely these disturbances are wanting which we have already learnt as diagnostic of that picture of disease. The patient certainly is often resistive, but she is not negativistic ; where it shows at all her resistance is soon overcome by outward influence. She is neither dull nor apathetic, but on the contrary is inquisitive and divertible, and reacts occasionally very actively to impressions and influences. Her movements are pos- sibly constrained and wanting in freedom, but are neither stiff nor affected. Her behaviour is not stereotyped and senseless, but is undoubtedly determined by ideas and desires, even if in rather a hazy way. If finally we seek to bring the clinical picture into consonance with the assumption of circular stupor, we encounter the essential difficulty that the mood of the patient is not depressed, but at all times decidedly cheerful, and that her whole appearance as well as her behaviour shows a tendency to be destructive, to adorn herself, and to joke. Before we seek to find a new interpretation of this condition, let us first cast a glance over the previous history. The patient's mother is very nervous ; her brother is eccentric. Phj'sically Conditions of Maniacal-Depressive Insanity 71 delicate and moderately gifted mentally, the thrifty and indus- trious patient married when twenty-one years of age. The day before the wedding she wept incessantly, and next day danced about in such strange excitement that a postponement of the marriage was contemplated. Then for three months she was sad and irresolute, and could not work, but at the same time showed great irritability. In her two first confinements this frame of mind was repeated, but disappeared after some weeks. After the birth of her third child, when she was twenty-six years of age, the woman again became ill in a similar way with appre- hension, depression, ideas of poison, and apparently also halluci- nations. As the patient gradually became quite stuporose and refused food, she was brought then for the first time to this hos- pital. After four months she gradually became more lively, wanted to get away, undressed herself, unloosed her hair, climbed up on chairs and tables, and tore up anything she got hold of. She decorated herself with rags and little green branches, was very dirty, and laughed and scolded to herself, but gave next to no information on being questioned ; on the contrary, she made an impression of inaccessibility, confusion, and dementia. Occa- sionally " flight of ideas " was to be remarked in her meagre conversation. Complete recovery, though with only dim recollection of what had taken place, followed after about a year's duration of the whole illness, accompanied by considerable gain in weight, which previously had been much reduced. At the age of thirty-four, after the patient had been through another state of depression, which was medically treated at home in spite of her own wish to return to the hospital, twenty-eight months ago — that is, three weeks after her last confinement — the malady set in anew. The patient became apprehensive, confused, expressed thoughts of suicide, fear of death, and wished to throw her child out of the window. When brought here two months ago she was wanting in intelligence, and in spite of evident effort could only slowly and with difficulty answer even simple questions ; she had a decided feeling of illness, complained of being in an apprehensive and uneasy mood, and also of incapacity for work. She heard calls, children screaming, noises as of running and driving, thought she was accused of and was to blame for everything, from time to time screamed loudly and monotonously, and sank rapidly into a pronounced stupor. After about four months the condition gradually changed, so that the patient got out of bed, laughed and grinned a great deal, 72 Lectures on Clinical Psychiatry scolded to herself, unloosed her hair, was habitually wanting in cleanliness, and with the greatest determination began to dirty and to tear her clothes. She undressed herself as often as she could, decorated herself with rags in all manner of ways and seemed very well pleased with the effect, laughed at the doctor, but otherwise remained almost quite inaccessible, sometimes ill-treated other patients, occasionally made use of very bad and abusive language. She also often wept, and had a feeble-minded, vmintelligent expression of face. The last time she was here she was rather more at ease mentally and more manageable, was pleased with the visits of her husband, but still remained almost always silent, and destroyed the clothes which had been brought from home at her request. As you will have seen, the whole clinical course of the malady, in its single attacks always ending in recovery, quite corresponds with that of maniacal-depressive insanity. Also the series of depressive attacks of short duration would perfectly fit in with the experiences we have so far discussed, and so would the begin- ning of both the lengthy illnesses observed in this hospital. It -is certainly true that on both occasions the further course differs in an exactly similar way from the recognised picture of depression. I do not think I can go wrong in the opinion that here the appearances of maniacal excitement have mixed with those of depression in a most curious way. A cheerful and occasionally irritable mood was associated with impediment of thought, and impediment of the will was broken through by the inclination to be doing, a sign usually indicating mania. In this way the clinical picture is formed of that " mixed condition " which we call " maniacal stupor," in which the patients are unintelligent, poor in ideas, dull, taciturn, or often absolutely dumb, while they give vent to their exuberance of mood in all sorts of tricks and adornments, as well as in vigorous abuse, jocular remarks, and play on words. If this assumption be right, although the patient might now be supposed to be mentally enfeebled on account of the severe impediment of thought, just as she might have been formerly, she will recover within fairly calculable time, but she certainly stands in danger of a subsequent relapse.* * The patient returned home at the end of eight months, substantially improved, and there, apparently, gradually recovered. Six years later, presumably under the influence of some new depression, she poisoned herself by taking hydrochloric acid. Conditions of Maniacal-Depressive Insanity ^^ Quite another form of these mixed conditions is shown by a farmer of fifty-three years, whom I will now show you. The patient gives coherent information as to his personal circum- stances, knows where he is, knows the doctors, but is not quite clear as to time. At first he behaves quietly, but in the course of the conversation becomes more and more excited, begs urgently to be allowed to go home to his wife and children, entreats once more to be pardoned. Can they answer for keeping him always and for ever in the penitentiary ? The attendants had said so ; he had seen in the crossed spoons that they would shackle him ; the five plates on the top of one another had meant that he would go no more to his family — four at home, and one here. He sees very well that they think him incurable, and will not eat another bite. He steals money from his children through his residence here. To-morrow he will certainly be put to death ; but why has he not taken heed thereof of what was meant when the cup was broken and the vessel stood in that way on the table ? He should have said, " I know not why," and demanded his clothes. In this confused way he talks on, only allowing himself to be interrupted for a short time, to immediately begin his lamentations anew. At the same time he shows active emotional excitement, wrings his hands, wishes to kneel down, groans and weeps aloud. All the same, his expression is not really sad. He looks round him with lively and sparkling eyes, answers questions between whiles quite to the purpose, is ready to make a compact that he will not speak and will eat regularly for eight whole days if he may go home, urging half jokingly that one must give him one's hand on it, but then falls again into his former loquacity. The physical examination shows no deviation from health worth noticing. The patient's condition, therefore, is one of depression. If we ask what this signifies clinically, we shall first think of melan- cholia, as general paralysis is little probable on account of the want of physical disturbances ; so also is a state of circular depression, there being full freedom of expression of the will. The only symptoms, perhaps, that do not so entirely fit into the picture of melancholia are the great loquacity of the patient, and the ease with which one succeeds in diverting him, if only for a time. If we now look back at the development of the condition, we learn that the patient comes of a healthy family, but has a son 74 Lectures on Clinical Psychiatry who is insane ; two other children are healthy. He was in the campaign of 1870, and was a quiet, sober workman, healthy till his forty-third year, when he was treated in this hospital for " melancholia," recovering after a short time. Now for about a year he has again been ill. The illness came on gradually. The patient had groundless anxieties, worked badly, and ex- pressed thoughts of suicide. According to his own account, he did not know in the morning whether he was to go out or whether he was to go in, whether he was to take the manure here or there. At last his wife said : " Now, do go away once and for all." Some days things went well with him, then again he thought he could never any more be happy. Why should he go on living ? Often he became excited and angry ; subsequently he regretted this. On admission to the hospital six months ago, the patient was in a cheerful mood, showed strong desire for talking, and had no feelings of illness. He said that now he could decide every- thing easily that had been so very difficult to him before. But next day the picture changed quite suddenly. The patient became forgetful, was only able with difficulty to give the names of his children, showed great apprehension, thought he was con- demned to death, slid about the ground on his knees, and refused to eat. But this condition changed quickly also, and now there developed a quite erratic alternation between exalted and apprehensive moods, which sometimes occurred within a few hours. The apprehensive mood, however, gradually gained the upper hand. Contradictory ideas of sin and persecution sprang up, and disappeared ; at the same time the patient, in the way in- dicated, had the inclination to refer every occurrence in his surroundings to himself. He was especially tormented by the compulsion to add, " I know not why," to all his observations, so as to come to no harm from them. In his " delusions of refer- ence " the great divertibility of the patient showed very dis- tinctly, always allowing him to find out new connections, while the old would be quickly forgotten. Great motor unrest showed during the whole illness, manifesting itself in lively gesticulations, continual wandering about, and particularly in the exceedingly strong desire for talking. In that respect the enhancement of the excitement by speech itself was worthy of notice. As soon as one addressed the patient, his torrent of talk unfailingly Conditions of Maniacal-Depressive Insanity 75 quickly rose up, however much he had firmly resolved to remain quiet. Latterly, a more cheerful, hopeful mood has for the time stepped in again. It is clear from the course of the attack that we have not here to do with a melancholic illness. The distinct maniacal colour- ing of the condition in the first weeks of the present attack, as well as the early appearance of the first attack of the illness, are contradictory to that throughout. At the same time, we see from the statements of the patient that incaf ability of resolution, which we have learnt to recognise as a symptom of circular depression, was very marked during the first time of the illness. We were also often able without difficulty to show an impediment of thought. The condition of the patient, therefore, in the beginning of the present attack showed symptoms already known to us as those of circular depression — that is to say, impediment of thought and will ; later, from time to time those of maniacal excitement — namely, cheerful mood, with desire for talking, though without marked " flight of ideas." Then, after a time of fluctuations backwards and forwards, the sad apprehensive depression again became stronger, while the motor excitement continued. In our opinion, this picture also belongs to the embodiments of maniacal-depressive insanity, and is to be described as a mixed condition of psycho-motor excitement with psychic depression. The patient shows us, therefore, as we believe, the very opposite of the picture in the preceding case, in which we could establish cheerful moods side by side with psycho-motor impediment. The grounds for these opinions are drawn chiefly from the marked, if at the same time transitory prominence of the ordinary maniacal and depressive conditions in the same patient in the same or in different attacks, alongside of the mixed states already described. The value of this interpretation consists in the fact that we gain through it a clear opinion as to the further course of the malady. If we know that conditions of this particular kind only represent maniacal-depressive insanity, we may expect recovery from the present attack, but in all probability a relapse will occur later on in this or in another form of the periodically recurring disease. This tendency to fall each time into mixed conditions of the same nature apparently often exists in the same patient ; sometimes, as in our first case, this tendency comes out only later on, yet an ordinary attack may appear, in 76 Lectures on Clinical Psychiatry addition, between several mixed attacks. As a rule, mixed con- ditions seem to represent rather more severe forms of the disease than simple attacks.* In maniacal-depressive insanity we have already been re- peatedly met by delusions, usually ideas of sin and persecution, more rarely ideas of grandeur. These delusions do not neces- sarily belong to the indications of the disease. They can be entirely wanting, but can also be so strongly developed that they give a deceptive character to the whole condition. You see here before you a student of music, aged nineteen, who has been ill for about a year. His old father is disabled in conse- quence of several apoplectic fits ; a brother of his became insane. The highly-gifted patient, without any tangible cause, while studying music, became depressed, felt ill at ease and lonely, made all manner of plans, which he always gave up, for changing his place of residence and his profession, for he could come to no fixed resolutions. During a visit to Munich, he felt as if people in the street had something to say to him, and as if he were talked about everywhere. He heard an offensive remark at an inn at the next table, which he answered rudely. Next day he was seized with the apprehension that his remark might be taken as lese majeste. He heard that students asked for him at the door, and he left Munich post-haste with every precautionary measure, because he thought himself accom- panied and followed on the way. Since then he overheard people in the street who threatened to shoot him, and to set fire to his house, and on that account he burned no light in his room. In the streets voices pointed out the way he ought to go so as to avoid being shot. Behind doors, windows, hedges, pursuers seemed everywhere to lurk. He also heard long con- versations of not very flattermg purport as to his person. In consequence of this, he withdrew altogether from society, but yet behaved in such an ordinary way that his relatives, whom he visited, did not notice his delusions. At last the many mocking calls which he heard at every turn provoked the thought of shooting himself. After about six months he felt more free, " comfortable, enterprising, and cheerful," began to talk a lot, to compose, * After twenty months' duration of the attack, the patient quite re- covered, with great increase of weight. Latterly he has been easily excited, and has taken to drinking. Conditions of Maniacal-Depressive Insanity J"] criticised everything, concocted great schemes, and was insub- ordinate to his teacher. The voices still continued, and he recognised in them the whisperings of master spirits. Hallu- cinations of sight now became very marked. The patient saw Beethoven's image radiant with joy at his genius ; saw Goethe, whom he had abused, in a threatening attitude ; masked old men and ideal female forms floated through his room. He saw lightning and glorious brilliancy of colours, which he inter- preted partly as the flowing out of his great genius, partly as attestations of applause from the dead. He regarded himself as the Messiah, preached openly against prostitution, wished to enter into an ideal connection with a female student of music, whom he sought for in strange houses, composed the " Great Song of Love," and on account of this priceless work was brought to the hospital by those who envied him, as he said. The patient is quite collected, and gives connected informa- tion as to his personal circumstances. He is clear as to time and place, but betrays himself by judging his position falsely, inasmuch as he takes us for hypnotizers, who wish to try ex- periments with him. He does not look upon himself as ill ; at the most as somewhat nervously overexcited. Through diplo- matic questions we learn that all people know his thoughts ; if he writes, the words are repeated before the door. In the creaking of boards, in the whistle of the train, he hears calls, exhortations, orders, threats. Christ appears to him in the night, or a golden figure as the spirit of his father ; coloured signs of special meaning are given through the window. In prolonged conversation the patient very quickly loses the thread, and produces finally a succession of fine phrases, which wind up unexpectedly with some facetious question. His mood is arrogant, conceited, generally condescending, occasion- ally transitorily irritated or apprehensive. The patient speaks much and willingly, talks aloud to himself, and marches boister- ously up and down the ward, interests himself more than is desirable in his fellow-patients, seeking to cheer them and to manage them. He is very busy, too, with letter-writing and composing, but only produces fugitive, carelessly jotted down written work, with numerous marginal notes. Physically, he IS well. The interpretation of this condition is not easy at the first yS Lectures on Clinical Psychiatry glance. Of the diseases hitherto considered, dementia praecox would perhaps come first and foremost under consideration, especially certain forms of it with which we shall have to deal later on. But the exceedingly fresh, active mood of the patient, his interest in his surroundings, his sociability, and his press of occupation, are decidedly opposed to this supposition. Also, the manifold peculiarities of action and behaviour which we saw stand out so prominently in that disease are entirely want- ing. On the other hand, the divertibility which is seen in his ever fijnng off at a tangent and so easily losing the thread of his narratives, in his cheerful, arrogant frame of mind, and in h s urgent need to he talking and doing, points to the relationshij) of the condition with maniacal-depressive insanity. And this opinion would be justified by the joyless, irresolute manifesta- tions, so characteristic of the first stage, passing into the com- fortable but active states, so noticeable in the second stage. Hallucinations and delusions, which in such cases frequently lead to the diagnosis of "periodic paranoia" — to be dis- cussed later on — are not such an essential clinical indication that they would contradict our interpretation ; they could be absent in one attack of the malady and present in another. If our supposition with regard to our patient be right, we are able to predict complete recovery in the near future, though the possibility of a subsequent relapse has to be admitted.* * The patient made a complete recovery, and remained well for ten years. Then a slight but decided depression followed, with repeated and distressing changes of decision in matters of importance, with incapacity for work, fluctuations of mood, and hypochondriacal disorders, which disappeared after lasting for about six months. This later appearance of simple, unmistakable circular depression without any trace of delusions or hallucinations is the best elucidation of the above reflections, written so many years ago. LECTURE IX KATATONIC EXCITEMENT Gentlemen, — ^The patient I will show you to-day has almost to be carried into the room, as he walks in a straddling fashion on the outside of his feet. On coming in, he throws off his slippers, sings a hymn loudly, and then cries twice (in English), " My father, my real father !" He is eighteen years old, and a pupil of the Oberrealschul (higher grade modern-side school), tall, and rather strongly built, but with a pale complexion, on which there is very often a transient flush. The patient sits with his eyes shut, and pays no attention to his surroundings. He does not look up even when he is spoken to, but he answers, beginning in a low voice, and gradually screaming louder and louder. When asked where he is, he says, " You want to know that too ; I tell you who is being measured and is measured and shall be measured. I know all that, and could tell you, but 1 do not want to." When asked his name, he screams, " What is your name ? What does he shut ? He shuts his eyes. What does he hear ? He does not understand ; he understands not. How ? Who ? Where ? When ? What does he mean ? When I tell him to look, he does not look properly. You there, just look ! What is it ? What is the matter ? Attend ; he attends not. I say, what is it, then ? Why do you give me no answer ? Are you getting impudent again ? How can you be so impudent ? I'm coming ! I'll show you ! You don't turn whore for me. You mustn't be smart either ; you're an impudent, lousy fellow, an impudent, lousy fellow, as stupid as a hog. Such an impudent, shameless. miserable, lousy fellow I've never met with. Is he beginning again ? You understand nothing at all — nothing at all ; nothing at all does he understand. If you follow now, he won't follow, will not follow. Are you getting still more impudent ? Are you 79 8o Lectures on Clinical Psychiatry getting impudent still more ? How they attend, they do attend," and so on. At the end he scolds in quite inarticulate sounds. The patient understands perfectly, and has introduced many phrases he has heard before into his speech, without once looking up. He speaks in an affected way, now babbling like a child, now lisping and stammering, sings suddenly in the middle of what he is saying, and grimaces. He carries out orders in an extraor- dinary fashion, gives his hand with the fist clenched, goes to the blackboard when he is asked, but, instead of writing his name, suddenly knocks down a lamp, and throws the chalk among the audience. He makes all kinds of senseless movements, pushes the table away, crosses his arms, and turns round on his axis, chair and all, or sits balancing, with his legs crossed and his hands on his head. Catalepsy can also be made out. When he is to go away, he will not get up, has to be pushed, and calls out loudly, " Good-morning, gentlemen ; it has not pleased me." The only physical disturbance worth noticing is a considerable acceleration of the pulse to i6o beats. At first sight, the patient might perhaps be considered maniacal, but closer consideration reveals several features inconsistent with this view. The first of these is the patient's inaccessibility. Although he undoubtedly understood all our questions, he has not given us a single useful piece of information. His talk was indeed connected with our questions, but it contained no answer, but only a series of disconnected sentences, having no relation whatever either to the question or to the general situation. Again, the frequent repetition of the same phrases could very plainly be followed in his talk, which finally degenerated into unmeaning abuse, without the occurrence of any external cause or the appearance of strong excitement in the patient himself. We have already learned to recognise some of the symptoms — the negativism shown in his refusal to answer, and perhaps in his keeping his eyes continually shut, and also the stereotypism. A new feature is confused speech, quite incoherent talk, without the patient's being irrational or showing strong excitement — a symptom which is not found in this form of mania. Maniacal patients may certainly talk in a confused way, but, at the most, it is only transitorily and in the worst states of excitement, with loss of memory, that they lose the connection so completely. Even then it is almost always possible to get some kind of relevant answer from them. And we only meet with the gross obscenity Katatonic Excitement 81 of speech known as " coprolalia " in maniacal patients when they are very much irritated. Other diagnostically important symptoms to be seen in our patient are catalepsy, sudden impulsive actions, grimacing, and extraordinary, affected behaviour. His remarkable attitude, his aimless movements, and the strange transformation of everyday actions, such as walking, speaking, and giving his hand, the so- called " mannerisms," are what principally distinguish his actions from the brisk and bustling activity of the maniac, which is so much more comprehensible to us who are sane. The senseless- ness of a maniacal patient's actions results from his great diverti- bility and the rapid succession of ever-fresh abortive impulses, but here the impulses themselves are quite aimless, and do not follow one another at all quickly, even though some particular impulse may be converted into action with violent suddenness. Hence, in mania actions beaV the stamp of flightiness and precipitancy, but here of incomprehensibility and absurdity. There the mood is exuberant and unrestrained, while here, in spite of all external unrest, the absence of profound emotional excitement is obvious enough. In accordance with these arguments, we will not hesitate to attribute the condition before us, not to maniacal-depressive insanity, but to dementia prcecox, of which we find the character- istic symptoms present here — viz., good comprehension, with atrophy of the emotions and various kinds of vitiations of the will. Our patient's father was a drunkard and temporarily insane, and his mother seems also to have drunk. The patient himself was always quiet and very industrious, but of moderate mental endowment. Seven months ago, during the holidays, he suddenly began to learn in a quite senseless way, and then became confused, thought he was laughed at for being dirty, and washed himself all day long, was afraid his effects would be taken, broke the windows, seemed to hear voices, attacked his mother without any cause, became wet and dirty in his habits, and would not speak a word. In the hospital he was almost dumb, was cataleptic, gave his hand stiffly and jerkily, and almost entirely refused to eat. His expression was generally indifferent, though sometimes cheerful, and visits from his relations made no impres- sion at all on him. The patient understood quite well what was taking place around him, but as a rule he did not obey orders ; indeed, be 6 82 Lectures on Clinical Psychiatry sometimes did the exact opposite of what was wanted. Thus, he shut his eyes when his pupils were mentioned, covered his face with his handkerchief if you wished to see it, and drew his hand back when he ought to have stretched it out. He was often dirty, and also smeared faeces about, and rolled them into little balls — a sign diagnostic of great emotional dulness. After refusing food for a long time, he suddenly asked for Swiss cheese and then for chocolate, and devoured them both greedily. From this we can plainly see the senseless and impulsive nature of his refusal of food. Once he laid his outstretched leg on the next bed, and remained in that position when the bed was moved away. In the seventh month of the illness the patient began to be ex- cited, after having sung occasionally during the period of dumb- ness. In the middle of the night he threw away his bedding, rocked rhythmically up and down on the bedstead, and screamed incessantly, " Now, I want to know where my brother is." Since then he has been in a continual state of excitement, is destructive and abusive, and talks in a confused way. He wrote to his relations, from whom he takes the eatables they bring when they come to see him, without talking to them much, that he was going to travel by Gibraltar to the Cameroons and by Con- stantinople to Bucharest. The opinion we formed from our momentary observation of the patient, that we had to deal with a condition belonging to dementia praecox, is fully confirmed by the history of the case until now. The disease began in the usual way with apprehensive bewilderment. This was followed by unmistakable katatonic stupor, succeeded rather suddenly by the present excitement. The essential features of this form of illness, repeatedly described by us, have remained the same in the two conditions, outwardly so different.* Our second patient to-day, a girl of twenty-nine, also shows marked excitement. When brought into the room, she lets herself slide on the ground, throws herself about, kicks with her legs, claps her hands, plucks at her hair, and makes it untidy, pulls out a whole bunch of it, makes faces, hides her face, and spits round about her. She does not generally react at all when spoken to or pricked with a needle, but resists violently if you * The patient was transferred to a nursing asylum five years ago, and afterwards improved and was handed over to the care of his family. He- is said to be well at the present time. Katatonic Excitement 83 try to take her hand or to pour water on her. She obeys no kind of orders. She will not show her tongue, and shuts her eyes as soon as you want to examine them. But, from isolated re- marks and answers quickly thrown out, it appears that she not only understands the questions, but is also pretty clear about her surroundings. But generally she calls out disconnected words, having absolutely no relation to her position, loudly and quite senselessly : " Pupp — bups — moll — you know — temperature — fire insurance — water — Weinheim — water — creolin — God damn you ! — twenty marks — say, what — water — creolin — don't look in — twenty marks — say, what is — away with it — thank you very much — twenty marks — say what you want — God damn you ! — water — not I — twenty marks — so — God damn you ! — dear child — so — fire-shy — stay at home with your wife — treasures oh — sow — say what you want — thank you very much," etc.- Meanwhile she croaks and crows, then suddenly begins to sing a hymn with expression, changes to a street-song, laughs without restraint, and breaks off abruptly with loud sobs. She is slightly built and very badly nourished ; her lips are cracked and covered with scabs ; her head is flushed and her pulse very hurried. In her mouth are fresh syphilitic ulcers, which can only be imperfectly examined on account of her strong resistance. What strikes one most in this severe state of excitement is the contrast between the complete confusion of expression in speech and the slight disturbance of comprehension and sense of her posi- tion. The patient addresses the doctor as " Herr Doktor," and makes pertinent remarks about what occurs around her, but does not answer the simplest questions, uttering quite disconnected words and exclamations slowly and deliberately. Here the frequent repetition of the same phrase is very marked, as is also the occasional playing with assonances and rhymes. In spite of her good comprehension, the patient does not seem to trouble at all about her surroundings, but maintains an attitude of re- fusal and resistance. Her mood is on the whole indifferent, only transitorily sad and more often cheerful. Her restlessness is aimless and monotonous ; they are not actions that she performs, but only movements. If we finally notice the grimacing, I think that the essential agreement of the condition before you with that of the first patient will be obvious. In both cases we find good comprehension with little attention, confused speech, stereotypism 6—2 84 Lectures on Clinical Psychiatry in talk and behaviour, negativism, and aimless unrest, and silly actions without deep emotion. This condition, too, belongs to the sphere of katatonia. Our patient's father was a drunkard, and she was but slightly endowed mentally. In her twenty-third year, as the result of a trifling injury to the head, perhaps with erysipelas, a change took place in her behaviour. She became shy, self-absorbed and very forgetful. She was apprehensive, thought there was a fire, and poured water on her bed, passed urine on her pillow, saw ghosts, and quickly fell into a state of violent excitement which seems to have been very like her present condition. Here in the hospital, where she was brought at that time, she gave no information, screamed out single disconnected words mono- tonously, took up extraordinary attitudes, and sank in a short time into a complete stupor, from which she awoke in a few weeks, unable to give any detailed account of her condition. After her discharge, she gradually began to lead an irregular and indiscreet life, in opposition to her previous conduct. She became syphilitic, and bore three illegitimate children, the last of which she suffo- cated in her bed a little after its birth. For this she was con- demned, in consideration of her limited intellect, to two years and three months' imprisonment. This experience has made very little impression on her mind ; she only smiled in an imbecile way if you spoke to her about it. After her condemnation, she still had to go through a course of mercurial treatment, but in eight weeks her mind suddenly gave way, and thus she came into our hospital again. She was then in a state of senseless excitement, scratched and struck herself, tore out her hair, threw herself ruthlessly on the ground, let herself fall out of bed, and had numerous bruises on her arms and legs. On washing out her stomach, a putrid fluid was discharged, while purulent slime and bloody mucous crusts came from her mouth. The patient occasionally gave sensible answers, but generally talked incomprehensibly and screamed continually for water, only to spill it as soon as it was brought to her. Her whole state was very much like what it is now, only far worse. By frequently washing out her stomach, by artificial feeding, and by the evacuation of the overfilled bowels, we succeeded with great trouble in improving her state of nutrition, which was much impaired. After only a few days the restlessness im- proved, and the patient, who appeared quite collected, took food III Katatonic Excitement 85 again in abundance. Now, lour weeks after her admission, there has been a return of the excitement for the last few days. We will try to combat it, as before, by feeding her as well as possible, and, if necessary, by artificial means, and by prolonged baths, which generally act extremely well in such severe cases. Prob- ably we shall soon succeed in tranquillizing her again. It seems very doubtful, however, if our patient's condition will ever be that of a sane person. In the first place, she was only slightly endowed from her youth up, but still, she has had some scanty education at school, as we were able to make out during the period of tranquillity. She also remembers her former visit to the hospital, and the doctors who were there at that time. This development of dementia prascox on a foundation of con- genital or early-acquired weakness of intellect is not altogether unusual, though we also see specially good scholars attacked by the disease. Our patient's prospects are rendered still darker by the fact that a profound change in her whole character seems to have followed her first illness. I have already told you that the improvement after the subsidence of severe katatonic disturb- ances is not generally a real cure. Even if we cannot at present completely exclude the possibility of complete and lasting recovery, experience shows that some remains or other of the ill- ness can usually be seen by an expert observer. These, and the tendency to relapses, prove that the disease has produced a certain degree of infirmity. Loss of moral and emotional feeling, absence of any understanding of the past illness, want of freedom in action and behaviour, signs of catalepsy, affectation, nega- tivistic obstinacy, and a reserved and inaccessible character are, as in our present case, the most important of its traces. The morbid nature of the change is often unperceived by those about the patient, but becomes clear afterwards when relapses occur. In the present case it would seem as if the patient's confinement, her trial and condemnation, and the mercurial treatment had worked together to produce a fresh outbreak of the disease. The result, even under the most favourable conditions, will be a high degree of feeble-mindedness.* The factory-girl, aged thirty- two, who now comes into the room * The patient has now been in a nursing asylum for nearly nine years. She is physically well, and remembers her illness and occupies herself, but has remained destitute of ideas, weak in judgment, and emotionally dull. Short but severe attacks of excitement have twice recurred. 86 Lectures on Clinical Psychiatry with an awkward and very deep curtsey, presents an entirely different aspect from the last patient. She declines to sit down to talk to us, thanks us for the " honour," goes up and down with affected, waddling steps, and begins to declaim and recite verses, and to interpolate witty remarks in our discussion of her condi- tion. Her name is what the parson christened her, and she is as old as her little finger. She knows her position, the date, where she is, and the people around her, and can give the most exact information about her past experiences. She does not consider herself insane. She often interweaves her disconnected talk with scraps of bad French and senselessly altered quotations, such as, " Ingratitude is the world's praise," " Many hands, many minds." She rides single phrases to death in uninterrupted repetition — " Devil's dung on the soul's foot, the soul's foot in devil's dung." She often uses very strange and almost incom- prehensible compound words and phrases. Her mood is silly, cheerful, sometimes erotic, and then again irritable. She takes pleasure in the most indecent sexual allu- sions, and occasionally in outbursts of the wildest abuse. She does not obey orders, and refuses to give her hand on the ground that they are her hands. She will not write, and pertly refuses to do anything she is asked. She chatters continually, and will not let anyone get in a word. Her speech is extremely laboured. She cuts the separate syllables sharply asunder, accentuates the final syllables sharply, pronounces g like k, and d like t, talks like a child, in imperfectly formed sentences, distorts words, inserts senseless expletives and strangely-formed words, and constantly changes the subject. All her movements and gestures are clmnsy, angular, and stiff, and are very lavishly employed, but monotonous ; she hops about, bends down, claps her hands, and makes faces. She has ornamented her clothes in an extraordinary way with embroidery and crochet-work of staringly bright wool. From her talk it appears that she looks on herself as the mistress of the house ; she pays the nurses and appoints them, and will get herself better doctors. Moreover, she complains of being exposed to sexual assaults, and says that her lungs, heart, and liver have been taken out. She says she is engaged to a doctor in the asylum where she was before. She tells her name with the prefix " von." She also seems to have heard voices, but will only make evasive statements about them. If we exclude the not very marked delusions and also the prob- Katatonic Excitement 87 able hallucinations, of which we cannot yet be quite certain, the morbid symptoms in this case He principally in the department of action. In the patient's inaccessibility to any advances we recognise negativism, in her speech and behaviour slereotypism, and, more especially, very strongly-developed mannerisms. On the other hand, her comprehension and memory are excellent. In the sphere of the emotions exaggerated self-esteem is to be noticed, with strong sexual excitement and great irritability. There is also a complete dulling of the sense of shame, which appears in the patient's coprolalia. Sympathy for others seems almost extinguished. The patient has become violent in the roughest way to those about her on numerous occasions and without any recognisable cause, and she has shown herself to be cunning, vindictive, and extremely ruthless. She does not worry about her future. She certainly asks for her discharge now and then, as she does not want to be shut up always, but she has absolutely no plans, and lives simply for the day. This, besides showing a certain tack of judgment, may prove the absence of those emotions which impel the sane to picture the future to themselves in hope and fear. It is evident that here again we have one of the forms in which katatonia makes its appearance. The patient is said to belong to a healthy family, and only has a deaf and dumb cousin, but was considered very selfish and obstinate herself from her youth up. She was first a servant girl and then a factory hand, had two illegitimate children, and then aborted once. About six months later, two years ago now, she saw gray men and women's heads, and heard knocking and voices which called abusive words to her. Later on she wrote a love-letter to the proprietor of her factory, and was dismissed and picked up helpless on the street. When taken to an asylum, she was quiet and collected at first, but soon had brief attacks of the most violent excitement, during which she undressed herself completely, hit out roimd her in a senseless way, and bit. Later on she showed a repellent, discontented disposition and a tendency to stereotypism and impulsive actions. When she was brought here a year and a quarter ago she presented the same picture as now in all essential features. It should perhaps be added that she showed echo- praxis, followed the same track — a figure of eight, for instance — for hours in the garden, and was very refractory. For a long time she had to be kept quite alone in the garden and in her room, 88 Lectures on Clinical Psychiatry because, though quite collected and free from great emotional excitement, she was very dangerous to the other patients. In the course of the last few months she has gradually become rather more manageable. We may hope that she will make some farther advance towards tranquillity. Yet there can be no doubt that the deep disturb- ances of the judgment, the emotions, and the will are no longer capable of complete reversal. In spite of her good comprehen- sion and memory, the patient is feeble-minded in a very high degree, and will always remain so.* * She has now been in a nursing asylum for five years, rather quieter, but in other respects unchanged. LECTURE X MEGALOMANIA IN GENERAL PARALYSIS Gentlemen, — You have before you to-day a merchant, aged forty-three, who sits down with a poHte greeting, and answers questions fluently and easily. He is clear about his surround- ings and position, and knows the doctors, but makes rather vague remarks about the length of his residence here, and cannot give the year of his marriage or the present date correctly, " because he has not had a calendar for a long time." He says that he was driven crazy by overstrain and badgering, but is quite sane again now, only still rather nervous. His power of work has been very much increased while he has been at the hospital by the good care taken of him, so that he can do a great deal of work, and has the most brilliant prospects. He thinks of starting a large paper manufactory on his discharge, which will be very soon. A friend is giving him the capital necessary. Besides this, Krupp, whom his friend knows very well, has placed a property near Metz at his disposal, where he will go in for gardening on a large scale. The neighbourhood is also very well suited for vineyards. He will have fourteen horses for the farming business, and set up a brisk trade in timber as well, which cannot fail to bring him in a tidy little sum. To the objection that all these affairs will not go off so smoothly, and that they will require large means, he answers confidently that he will overcome the difficulties by his great power of work, and that, with his magnificent prospects, he cannot be short of money. He also hints that the Emperor is interested in him, and will allow him to resume the title his grandfather abandoned for want of means ; indeed, he might really use it now. The patient makes all these statements in a quiet, practical tone, behaving in a perfectly natural way. Even without my telling you that, as a result of his illness, «9 90 Lectures on Clinical Psychiatry this man's affairs are in anything but a good position, and that he has absolutely no prospect of making anything irk the way he proposes, you would have guessed that his is a case of morbid hopes or ideas of grandeur. This is confirmed by the matter- of-course way in which he sets aside the difficulties involved in his projects, and his readiness to extend his plans still further at the least incitement. If you suggest that poultry-breeding might be profitable, he says at once that of course he will keep turkeys, guinea-fowl, peacocks, and pigeons, fatten geese, and set up a pheasantry. This characteristic form of megalomania, the confident throwing out of ever-growing and easily-influenced plans, without any consideration of the difficulties in the way, is in high degree diagnostic of general paralysis. The same kind of thing is certainly observed in maniacal states, but there it is associated with s^Tnptoms of excitement, such as flight of ideas, loquacity, and a mood delighting in action, while our present patient, with his supposedly brilliant prospects, seems remark- ably quiet and indifferent. We will now remember his uncer- tainty about dates, besides subjecting him to a searching physical examination. The patient is a tall, lank, strongly-built and fairly well- nourished man. His expression is rather languid and tired. The left labio- nasal fold is rather less marked than the right. Both pupils are very small, and show no contraction on ex- posure to light, while the reaction on looking at a near object is maintained. The tongue shows no tremor ; the outspread fingers tremble a little ; the knee-jerks are exaggerated. In pronouncing difficult words like " Elektricitat " (electricity) or " dritte reitende Artillerie-brigade " (Third Brigade of Horse Artillery), the patient begins to stutter, and brings out the syllables in the wrong order. This form of disturbance of speech, called " syllable stumbling," and indistinct pronuncia- tion of the individual letters, are among the commonest signs of general paralysis. In conjunction with the reflex sluggish- ness of the pupils, the uncertainty about dates, and the charac- teristic megalomania, they leave no doubt that the patient is really suffering from general paralysis of the insane. As to the development of the disease, we know that the patient belongs to a healthy family, but has led a very restless life, and suffered from syphilis. His illness began about two years ago. He became absent-minded and forgetful, to such an extent at Megalomania in General Paralysis 91 last that he was dismissed by the firm for whom he had worked. Then, a year ago, he became excited, made extensive purchases and plans, weeping now and then in the deepest despair, so that he had to be taken into the hospital. On admission, he felt full of energy, " mentally and physically as well as ever," and intended to write verses here, where he was particularly com- fortable. He could write better than Goethe, Schiller, and Heine. The most fabulous megalomania quickly developed. He proposed to invent an enormous number of new machines, rebuild the hospital, build a cathedral higher than that at Cologne, and put a glass case over the asylum. He was a genius, spoke all the languages in the world, would cast a church of cast-steel, get us the highest orders of merit from the Emperor, find a means of taming the madmen, and present the asylum library with 1,000 volumes, principally philosophical works. He had quite godly thoughts. These ideas of grandeur changed continually, arising in a moment, to be quickly replaced by others. The patient showed great divertibility, an overhappy mood, easily passing into a tearful one, and great motor unrest. He talked, wrote, or calculated without ceasing, and c^rdered off-hand everything he saw in the advertisement-sheets of the newspapers — provisions, villas, clothes, furniture, etc. Soon he was Count and Lieutenant-General, presented the Emperor with a whole regiment of field artillery, and offered to move the asylum on to a mountain. Sometimes he was irritable, quarrelled with the other patients, and was destructive, but he always grew tranquil again. There was often retention or involuntary passing of urine. Two months after his admission the patient began to com- plain of hallucinations of hearing. Friends stood outside and talked about him, or he heard his children being violated. The news of large presents of money was also communicated to him in this way. Warders seized his sexual parts at night, and there were poison and black-lead in the food. He became gradually and continuously quieter, and fell into the state of mental weakness in which you see him now, devoid of judgment, emotionally dull, and feeble of will. His weight, which fell very much at first, has gradually increased by no less than 20 kilo- grammes.* * When the paralysis had lasted three and a half years, the patient died, quite demented, of miliary tuberculosis. 92 Lectures on Clinical Psychiatry The course described here is very common in general paralysis. After the introductory symptom of loss of mental strength, and especially of memory, there follows a time of excitement, with an exaggeratedly cheerful mood, and more or less pronounced megalo- mania ; then the excitement subsides, but the feeble -mindedness remains. This form is usually called classical general paralysis of the insane, because it was the first which was accurately known to alienists. When at its height, the disease may present a great resemblance to maniacal states, but the physical examina- tion and proof of the defective memory will save us from con- fusing it with them. So also will the senseless nature of the plans and the possibility of influencing them, and the feebleness and yielding character of the manifestations of the will, which are all greater in general paralysis. We have already seen, in our discussion of the depressive forms of the disease, that megalomania is not a necessary accom- paniment of general paralysis. The compariscn of such cases with that of our present patient shows at once that neither the purport of the delusions, nor the hallucinations, nor the bias of the mood are essential to the diagnosis. We often see ideas of grandeur and insignificance and cheerful and apprehensive mocds mingled with or directly succeeding one another in this disease, just as we do in maniacal - depressive insanity and dementia prscox. We have already met with indications of this behaviour in some of the cases discussed. The telegraph official, aged thirty-four, whom I will now place before you, affords a very instructive example of this. He is slender and prematurely gray, pale - looking, but fairly well nourished. He comes in with a beaming expression, greets us politely, describes his personal circumstances, knows where he is, and knows the doctors, but becomes uncertain and involves himself in contradictions as soon as he is asked for more detailed statements about the length of his stay here and important events in his life, and for the dates of his marriage, appointment, and dismissal. He is very fond of talking, ingenuously relates tender incidents of his married life, complains of his father-in- law, brags in all kinds of obvious ways about the part he took in the campaign of 1870-71, and plumes himself on the excellence of his oflicial work in a childishly simple manner. He had been recommended for the Iron Cross of the first and second classes, but the sergeant burned the list of recommendations in a fit of Megalomania in General Paralysis 93 officialdom. However, he would appeal to the Emperor now, and get permission to wear the decorations from him. The old Emperor William had granted him 6,000 marks to visit a watering- place. He would write a book about the sergeant, which would make a great sensation. He was not ill at all, and could enter on his duties any day. He had a brilliant career before him, and at the most would only go away for a few weeks for a change of air. Then in a few years he would be Post-Master. He pays no attention to objections, but sets them aside with a phrase or two, or replaces his assertions with others not less improbable. His knowledge is quite good, and he can give a fairly complete, though rather confused, account of his duties. He becomes very uncertain in doing sums with high figures. His mood is contented, confident, and joyously hopeful. Even a reference to his present unfortunate position, far from his family, without a place and without means, does not affect him much. He has recovered now, and has such excellent testi- monials that he can never be at a loss. He has written out some of these testimonials from memory, and lays them before us. We see that apparently there are real papers corresponding to these records, but there are exaggerated praises and embellish- ments in them which cannot possibly have occurred in the originals. For instance, it is stated that he brought about the fall of " the greatest criminal in Hamburg." He also shows us an address to the Prussian Minister of War, in which he begs him to be kind enough to support his application to the Emperor for the grant of a decoration and pecuniary aid. In this docu- ment he gives references to his former officers, whose visiting- cards he has, to prove that he has " been through it all." In these papsrs we notice that the patient often leaves out some letters and words, writing, e.g., " samlich " for " sammtlich,' doubles others, and strays from the proper construction of the sentences. Thus, he remarks that he " was present at the following battles and engagements," but does not name them, and goes on, " Am also for the Iron i as also 2d class, as well as for the Mecklenburg Cross of Merit, the which I took part in the campaign 70/71, and were present at the entrance into Berlin." The writing itself is good, but shows many little irregularities and bends. In spite of his plans for the future, the patient is not very anxious for his release, lets himself be diverted and consoled 94 Lectures on Clinical Psychiatry very easily, and agrees at once to stay here for some time longer. He does not worry at all about the position of his wife, who has gone back to her parents, or about the long time he has lost, or his discharge from the service, and receives the assurance that he is still insane with an incredulous smile, but without excite- ment. The result so far obtained from the examination — the great weakness of judgment, memory, emotional feeling, and volition, the ideas of grandeur, and the deterioration of the writing — will already have convinced you that the case now before us, re- sembling the last in so many respects, belongs to the province of general -paralysis. A searching physical examination shows that the labio-nasal folds are effaced, and the tongue trembles strongly when put out. Both pupils are inactive to light, and the knee-jerks are much exaggerated. In rapid speech, especi- ally when repeating difficult words, the separate letters are indistinctly pronounced, and sometimes omitted, changed, or transposed. " Slurring," lisping speech and syllable-stumbling may also be noticed. The development of this condition is very remarkable. Nothing certain is known about the patient's family, and it is impossible to tell if he has suffered from syphilis, but his marriage was childless, and, indeed, he declares that he never had sexual inter- course with his wife. According to his own account, he com- mitted a theft in his youth, and served a term of two years' imprisonment. After this he took part in the campaign, entered the telegraph service, and seems to have been a worthy official. Eight years ago he fell ill for the first time of appre hensive depression. He thought that his youthful offence was known, that it was alluded to in the newspapers, that his col- leagues would have no more to do with him, and that the authorities would dismiss him. As the result of this, he thought his life was ruined, became secluded, left his home, and only came back two days later, not knowing where he had been in the interval. At that time he spent four months in the hospital here, and was discharged rather better. No physical symp- toms could be discovered. His condition improved still further alter his discharge, and he married and was promoted in the service, although he had often behaved strangely during the first few years. Two years ago — that is, after an interval of nearly five years Megalomania in General Paralysis 95 — he was brought to the hospital a second time, having developed gradually increasing apprehensive depression, with refusal of food and great loss of physical health. The patient now pre- sented the picture of stupor. He hardly spoke at all, and lay in bed with a gloomy, surly expression, taking no interest in any- thing, and refusing food with great obstinacy. It gradually became evident that he was suffering from hallucinations of hearing of disagreeable purport, and felt himself to be influenced by " transferences." There was dung in the bread and poison in the soup, and the meat was rotten, and stank like the plague. The patient's mood was very discontented and ill-humoured, and he seemed to be annoyed whenever he was spoken to. He was not at all clear about his position, and made no attempt to get a correct idea of his surroundings or of relations of time. The condition lasted thus, with slight fluctuations, for fully eighteen months, until one day the pupils, which had been very frequently examined, were lound to be inactive to light. They remained so from that time onwards, and inequality of the pupils also appeared from time to time. Retention of urine, and later on weakness of the bladder as well, were observed. The patient gradually became more accessible, and now developed the idea that he had grown all crumpled up, and was 9 inches shorter. He complained bitterly of the whole treatment, and especially of the artificial feeding, so long necessary, which he said had made him ill. But he now began to eat of his own accord, gained 28 kilogrammes in all — 20 in seven months — and grew more and more into the state of happy feeble-mindedness in which you see him now. I think we can hardly doubt that the first illness eight years ago was the beginning of the paralysis. This view is supported by the circumstance that the condition at that time bore a very great resemblance to the subsequent attacks, and that the patient was peculiar for some time in the interval. In spite of that, he married and performed his difficult official duties for nearly five years. Such a course, with an introductory stage of depression and tnen renewed depression, followed by exaggerated cheerfulness, reminds one strongly of circular insanity, and cases of this kind, with alternations in the patient's condition taking the form of attacks, are often called " circular paralysis." It is well known that pauses in the disease, lasting for years, take place in general paralysis, with subsidence of all the 96 Lectures on Clinical Psychiatry symptoms, yet cases like this are somewhat rare exceptions. It is also very important that no physical signs of paralysis could be found, not only in the first attack, but also for a long time in the second. We may therefore sometimes have to reckon with the possibility of general paralysis, even where hardly any of the recognised physical symptoms can be found at first. But it will hardly be possible in such cases to decide that general paralysis exists, and we will find it very difficult to distinguish it from circular and katatonic stupor. Perhaps the dulness and want of marked emotion may some- times put us on the right track in the first case, and the absence of the diagnostic disturbances of volition — negativism, stereo- typism, and mannerisms — ^may guide us in the second. The continuous confusion and incapacity to get a correct idea of time and things might also be made use of.* Most important of all is the aid to diagnosis afforded by cytoscopy, a method of recent application, which will be described in a subsequent chapter. The duration of general paralysis, which varies within very wide limits, will, of course, be greatly prolonged by a number of remissions. On the other hand, there are cases in which the whole course of the illness is very rapid and stormy. I will now show you a tradesman, aged forty-three, who entered the hospital two months ago. He has complained of headaches for a year, and for four or five months he has fallen off in his work. His eldest brother died of an illness like his own, and he has always drunk a great deal himself. Nothing is known of specific infection. The patient became irritable and loquacious a few weeks before his admission, and made great plans. He suddenly bought a bathing establishment for 35,000 marks, although he had no means, ordered 14,000 marks' worth of champagne, and 16,000 marks' worth of white wine, to set up a hotel, bought a dagger and some arsenic, and had an attack in which he became quite rigid. You can see that the patient is now very much excited. He has torn up part of his clothes, and decorated himself with the shreds in an extraordinary way. He has tied strips round his legs, taken off his jacket, and turned his trousers up high. He chatters unceasingly, and develops the most fabulous ideas of * Our patient died in another asylum, after the disease had lasted nearly eleven years. Megalomania in General Paralysis 97 grandeur. He says he will have himself made bigger, so as to weigh 30 stone, is having steel bars put in his arms, wears iron orders weighing 2 cwt., is making himself fifty negresses with an iron machine, will always remain forty-two years old, and is marrying a countess of sixteen, with a fortune of 600 million marks, who has been awarded the rose of virtue by the Pope. He has horses which do not eat any oats, and 100 golden castles, with swans and whales of the stuff the bullet-proof breastplates are made of. He has made great discoveries, has built the Emperor a castle for 100 million marks, is on the most intimate terms with him, has been given 124 decorations by the Grand Duke, and is making every poor devil a present of half a million marks. Besides all this, there are ideas of persecution. They have wanted to murder him five times, and suck two tubs full of blood from his posteriors every night. For this he will behead the warders, or have them torn to pieces by dogs. He is building himself a steam guillotine. In spite of his continual screaming, chattering, and singing, it is possible to get a few short answers from the patient. He gives his name, knows he is in the " sick-house for madmen," knows the doctors, and can tell the date approximately, but always keeps straying from the subject to return to his fantastic ideas. His mood is exalted and blissful, yet he suddenly begins to weep bitterly when he speaks of the imaginary death of his wife, but immediately goes on to say that he is marrying a baron's daughter with money now. He is irritable at times, and gets into a rage, but is soon quieted by friendly persuasion, and by our entering into his delusions to divert his mind. His speech is hurried and indistinct, with an ill-defined, slurring articulation and syllable-stumbling. His writing shows trans- position and doubling of letters, and the characters themselves are unsteady. His features are flabby, and when he speaks there are active sympathetic movements of the face. His tongue trembles strongly, and is put out by jerks. The left pupil is considerably larger than the right, and both are inactive to light. His head is flushed, and his pulse frequent. The skin and knee reflexes are considerably exaggerated. The patient's susceptibility to pain seems to be reduced when his attention is diverted, and, strongly as he is built, his weight is gradually diminishing. You will see at once that the patient has general paralysis 7 98 Lectures on Clinical Psychiatry from the result of the physical examination, the extraordinarily disconnected delusions, the feeble mutability of mood, and the ease with which the will is overpowered. Here we see that type of the disease which is usually called the agitated form, from the predominance of strong excitement. This variety of the disease generally develops rather quickly, as it has done in the case before us. There may be remissions in its further course, or the excitement may increase continually, so that the patients succumb in a short time to exhaustion, either in a paralytic attack, or as the result of some other accident. This is called " galloping paralysis." This last possibility is not out of the question in the case before us, for the patient is often quite senselessly excited, injures and dirties himself, and puts the greatest difificulties in the way of treatment. Our task will consist essentially in taking care that he is properly fed, and in the employment of prolonged baths. The administration of hypnotics — sulphonal, trional, or hyoscin — cannot quite be dis- pensed with, on account of the patient's extraordinary restless- ness. It remains to be seen if we shall succeed in piloting him through his present danger by the means we are employing.* * The patient lost weight continually, and succumbed to collapse when^ he had been three months in the hospital. LECTURE XI ALCOHOLIC MENTAL DISTURBANCES Gentlemen, — ^The innkeeper, aged thirty-four, whom I am bringing before you to-day was admitted to the hospital only an hour ago. He understands the questions put to him, but cannot quite hear some of them, and gives a rather absent- minded impression. He states his name and age correctly. As to his previous life, we learn by broken scraps that he attended school up to the lower first class (the first class being the highest), and afterwards led an adventurous life for some time in America, after having failed to get into the railway service at home through colour-blindness. After two years he came home for some time, but then returned to America. There he seems to have made his living chiefly as a pianist, but he also had all kinds of other occupations, and was finally employed in a hotel. Eight years ago he came back to Germany, and began first one thing and then another, and for the last six months has kept a hotel. He says he has been in the asylum once already, and has had delirium from drinking. Yet he does not know the doctors, calls them by the names of his acquaintances, and thinks he has been here for two or three days. It must be the Crown Hotel, or, rather, the " mad hospital." He does not know the date exactly. Even during this conversation, in which the patient has made perfectly connected statements, you will have been struck by his restlessness. He moves about in his chair, looks round him a great deal, starts slightly several times, and keeps on playing with his hands. Suddenly he gets up, and begs to be allowed to play on the piano for a little at once. He sits down again immedi- ately, on persuasion, but then wants to go away " to tell them something else that he has forgotten." He gradually gets more 99 7—2 loo Lectures on Clinical Psychiatry and more exerted, saying that his fate is sealed ; he must leave the world now ; they might telegraph to his wife that her husband is lying at the point of death. We learn, by questioning him, that he is going to be executed by electricity, and also that he will be shot. " The picture is not clearly painted," he says ; " every moment someone stands now here, now there, waiting for me with a revolver. When I open my eyes, they vanish." He says that a stinking fluid has been injected into his head and toes, which causes the pictures one takes for reality ; that is the work of an international society, which makes away with those " who fell into misfortune innocently through false steps." With this he looks eagerly at the window, where he sees houses and trees vanishing and reappearing. With slight pressure on his eyes, he sees first sparks, then a hare, a picture, a head, a washstand-set, a half-moon, and a human head, first dully and then in colours. If you show him a speck on the floor, he tries to pick it up, saying that it is a piece of money. If you shut his hand and ask him what you have given him, he keeps his fingers carefully closed, and guesses that it is a lead-pencil or a piece of indiarubber. The patient's mood is half apprehensive and half amused. His head is much flushed, and his pulse is small, weak, and rather hurried. His face is bloated, and his eyes are watery. His breath smells strongly of alcohol and acetone. His tongue is thickly furred, and trembles when he puts it out, and his outspread fingers show strong, jerky tremors. The knee-reflexes are somewhat exaggerated. No irregularity can be seen in the pupils. There is a rather important enlarge- ment of the heart. The picture of disease before us is distinguished by some features which do not occur in the same way in any other con- dition, and therefore make a definite diagnosis possible at once. The first of these is the want of clearness in the ideas of time and place, with almost complete collectedness. You may converse with the patient for a long time without noticing his mental disturb- ance, till you suddenly find that he has no idea where he is, and completely mistakes everyone present. Paralytics may indeed, under some circumstances, present a similar picture, but in those cases the recollection of past evefits is always considerably dis- turbed, while here it is perfectly trustworthy for all occurrences up to the last few days or even hours. The mingling of true and false perceptions in our patient is, if possible, even more character- Alcoholic Mental Disturbances loi istic. Without noticing any contradiction, he sits now as a tippler in the Crown and now as a patient in the hospital, now with innkeepers and customers, and now with doctors around him. This incapacity to correct such obvious inconsistencies, while fairly collected and with good control over the memory, reminds us of many experiences in dreams, and shows that we have to deal with a delirious condition, a dreamlike obscuration of conscious- ness. If to this we add the vivid hallucinations of sight, the restlessness, the strong tremors, and the smell of alcohol, we have all the essential features of the clinical condition called delirium tremens. The mood, too, is strangely complex. It almost seems as if, side by side with the apprehension of threatening danger, there were a certain appreciation of the senseless nature of the delusions and of the ludicrous contradiction between fact and fancy. But a humorous perception of their condition is char- acteristic of drunkards in general. Delirium tremens is a very short-lived disease, generally running its course in four or live days, and only develops on the soil of chronic alcoholism. Our patient has drunk hard since he was thirteen years old. His father was easily excitable, and an uncle was formerly a very hard drinker. One of his aunts kept an inn, from which he had to take out the beer as a boy, and so he was treated everywhere. At home he got a quarter of a litre of wine every day, and also drank a great deal in a school-club to which he belonged. He learned to take spirits in America. At last, by his own account, he drank 6 or 7 litres of wine a day and five or six stomachic bitters, while he took hardly any food but soup. Some weeks ago he had occasional hallucinations of sight — mice, rats, beetles, and rabbits. He mistook people at times, and came into his inn in his shirt. His condition has grown worse during the last few days. The further course of the case will presumably shape itself so that all the disturbances will disappear rather suddenly in a few days.* The return of mental clearness generally takes place after a long sleep, exactly recalling the awakening from a feverish dream, while, at the height of the disease, sleep is usually almost entirely absent. When the delirium has ceased, the patients are * The delirium ran its course in six days. The patient has returned to the hospital six times in the following six years, sometimes of his own accord during intoxication or in the depression following it, some- times showing signs of delirium. He is extraordinarily weak in will, and quite unfit for any regular employment. I02 Lectures on Clinical Psychiatry of course still far from well, and the symptoms of alcoholism continue, although their presence may hardly be noticed in the shelter of the hospital. After repeated attacks, more especially, the delirium often passes into a more or less severe form of Korssakow's psychosis, a condition which will be described in a subsequent chapter. Now and then, too, a peculiar mental in- firmity, with hallucinations and strong delusions, follows delirium tremens. From 3 to 5 per cent, of the patients, or under un- favourable circumstances even more, quickly succumb to in- flammation of the lungs, heart weakness, accidental injuries, or suicide. Our patient, as he says himself, has been in the hospital once already, and that only four months ago. The clinical picture he presented then was exactly the same as now, only there were glycosuria and severe pain on pressure on the great nerve- trunks. On that occasion also there had been isolated hallucina- tions for some time before : the patient saw rats and mice, gave expression to ideas of jealousy, and threatened his wife and servant-girl with a revolver. WTien he was admitted, he had brought a bottle of strong wine with him, at which he took a last hearty pull. Next morning he had three epileptoid seizures, with convulsions. The delirium lasted about six days, after which he was quite clear, and gave us a sketch of his experiences during the attack. He thought it was " Papus Day," when the devil goes about. He ran his head suddenly against a marble pillar, and tried to turn away, but sideways across the street a huge slab of marble set itself opposite to him, and the same thing happened when he tried to turn back. The two slabs fell together threateningly against him. Two desperate figures brought him to the Oxen Church on a wheelbarrow, and laid him on the bier. A master of the ceremonies set hot rays against his mouth with red-hot shears, so that his life-strength gradually dwindled. At his request, he was given a glass of red wine, but Satan himself dashed a second glass out of his hand with a sneering smile. He then bade the bystanders farewell with all kinds of pious ex- hortations, and went away. At the same time, the corpses of the patient's four daughters were laid by his side. He was now to be punished in the next world with that in which he had sinned on earth. He continually felt an extraordinary thirst, but as often as he reached out for a jug or a glass, it vanished out of his hand. Alcoholic Mental Disturbances 103 Next morning he lay alive again on the bier in the Oxen Church, and the children with him, in the form of white hares. There was a procession of the Catholics, with which he was obliged to co-operate. While litanies were being sung in the next room at the Crown, he had to stamp on an immense number of gold spectacles lying on the ground, and there was a report each time. Those who took part in the procession then debated whether he should merely be hewn in two or struck really dead. The hostess of the Crown was for the first of these alternatives, on condition that he should live there permanently. He wanted to go away, however, because he got no beer. Then a sergeant- major came to release him. The landlord of the Crown shot at the sergeant-major with a revolver, and was arrested and taken off to prison. Another evening the whole Protestant community was in the church. A student's corpse was the central feature of the cere- mony, fifty of the members giving a kind of circus performance before the service. Next the patient noticed that his wife retired into a pew with a relation. Then he hid behind the pulpit with a Sister of Mercy, and saw how they desecrated the sacred building. Then he was locked into the church, but a glazier cut a hole in the window, so that beer at least could be handed in. When he dressed, he found that all the sleeves and openings in his clothes were blocked and sewn up and the pockets ripped open. Then, in his bath, he saw that he was surrounded by seven hares, swimming under water and splashing and nibbling him continually. This brief abstract of the patient's description of his delirium gives us a clear idea of the dreamlike condition in which particular real perceptions, like his knocking his head, are mingled with numerous very vivid false perceptions, especially of sight and hearing. As in a dream, a whole series of the most strange and remarkable events take place, with occasional sudden changes of scene. Patients often find themselves at their work in these visions, and we may observe this " business delirium " in the present case — the demand for the quenching of the thirst for alcohol being prominent all through. In our second patient also, a merchant, aged forty-eight, you will notice hardly anything remarkable at first. He gives a perfectly connected account of his life, and says that he served in the war and got a bullet in his foot. He can tell the date, knows where he is, and says that he is excited because people I04 Lectures on Clinical Psychiatry have climbed in at his window at night. Suddenly he cries, " That is aunt shrieking," and declares that he sees a child stand- ing over there. Then he looks out of the window and says, " I believe it is she ! Or not ? Yes. it is she !" He will not admit that these are hallucinations. With pressure on his closed eyes, he sees mist, then a red streak, and then a bank, on which two girls and an old lady are sitting ; they hold up their hands. Near them is a bear, and over that an ass. " That is a gen- darme— stop ; another gendarme, then a policeman." These were pictures, such as there are in children's spelling-books, and he thought he could see them through a chink between his fingers. He tells about his adventures with the nocturnal intruders in a rather confused way, and always takes it for granted that we know about them already. But gradually we learn that after a rather long spell of hard work, during which he had drunk a great deal regularly, he drank very hard for a few days, eating very little and getting no rest. Five days ago, when he went to bed after a heavy bout, he noticed little snakes and scorpions running about on the walls, and frogs and rats on the floor. He kept quiet next day. In the evening two men came in through the window, and called to him, " Good-evening, Charley !" They did not answer when he spoke to them, and when he hit at them with a stick he only struck the air. Later on they knocked at the window again, and threatened him ; then a whizzing began in his head, and he fainted. Next evening two gentlemen, two ladies, and two children came into his bedroom, sat down, and whispered together. One of the gentlemen came to his bed, and demanded his signature to a bill of exchange for i,ooo marks. This time also the figure did not wait to be seized, but vanished immediately ; the door was banged, and a voice cried, " Good- bye till to-morrow." The ladies and children, however, remained lying on the sofa, and then came to the bed and apologized. After working actively next day, in the afternoon the patient saw two men standing in the passage of the house, talking to each other. Three fellows grinned through the window, and his pen- holder bent and curtseyed. In his apprehension, he went and tossed off two or three glasses of wine in a neighbouring public- house. When he came back, he still saw the men standing in the passage, but got no answer to his greeting. As he heard un- canny laughter from several people in the yard, he tried to set on his dog, but it would not move. He heard his manager doing Alcoholic Mental Disturbances 105 business with a gentleman in the next room, although all the doors were shut, and he looked at them both through the fanlight in the door. Then an attack of giddiness came on. As the result of these experiences, the patient thought of suicide, but was kept from it by the appearance of his little daughter. The two gentlemen came to him again, and begged him to sign the bill without any more delay. On going for a walk, he was astonished to see cavalry, whose horses went on stilts 2 metres high, charging the piles of hop-poles standing in the fields. His daughter, who was with him, tried in vain to talk him out of his ideas. When he got home he saw grinning faces everywhere, and horsemen fighting in the air with golden spears. A gentle- man drank to him in a tumbler, saying, " You don't get away from us to-day, even if you have a dozen dogs with you." The men then offered him his own cheque-book, which he kept under a double lock, and tried to force him to sign, but they disappeared when he screamed. Then the wall opened, and a long procession came into the room, led by a " president " in a uniform covered with gold. He understood that the president's daughter was celebrating her engagement with an entertainment at which wine would not be spared. The patient was offered some. He complained of their breaking into his house to the president, who thereupon became visibly smaller and vanished into the wall. He came back, however, with wine and other good things, which he offered by way of an apology, and invited the patient to a concert. The banquet came to an end, and the whole company vanished. Then a voice summoned the patient to come to the concert, and he rode there with a companion, through the air. It was quite dark in the concert-hall. The music sounded through a long pendulum. A collection was made for the patient, producing 740 marks and some watches and diamond rings, but someone made off with the money, at which the presi- dent swore that he would be his death, and promised to send everything next morning. Next, the patient found that a couple of lovers had stolen into his house, so he had recourse to the police, and was brought by them to the hospital. The patient tells about his experiences in a mood which is half perplexed and half amused, crying now and then because he ought to be at home at his work. He seems still to be convinced of the reality of the events described. Slight restlessness is also plainly seen. The physical signs are strong tremors of the out- io6 Lectures on Clinical Psychiatry spread fingers, a little uncertainty in speaking, and contraction and bad reaction of the pupils , but the last of these disturbances may be referred to the large use of opium during his illness. His liver is enlarged, and there is sugar in his urine. We see again in this patient a number of features we learned to recognise in the previous case — the characteristically fantastic and dreamlike experiences, the extraordinary clearness to the senses of the hallucinations, the half-apprehensive, half-humorous mood, and the restlessness and tremors. On the other hand, the patient, for the time, has a correct idea of places and things. That seems generally to have been the case during the course of his illness, but at times it was not so — e.g., during the delirious concert. We cannot therefore look upon the difference as essen- tial, but only as one of degree. Lastly, in this patient also we have been able to call up hallucinations by suggestion when the eyes are closed, a phenomenon very frequent in sufferers from alcoholic delirium. We will therefore not be wrong in assuming that this is also a case of delirium tremens.* Both patients had sugar in their urine, though it was only found for a short time in the first case. This is not a regular symptom, but at the height of the disease albumin may generally be found in the urine, and certain changes seem to take place in the blood. All these phenomena point to this conclusion : that the abuse of alcohol leads to severe disturbances in the physical economy, which we must apparently consider to be the direct and immediate cause of delirium tremens. There can hardly be any question of immediate alcoholic poisoning, because the clinical picture is very different from that of intoxication, and also because the delirium ends in a few days, even if drinking is continued. Moreover, the delirium may set in after some time of complete abstention from alcohol. Our present cases also show that the withdrawal of alcohol is in no way responsible for the out- break of the delirium. Both patients went on drinking till the disease was completely developed. This is not without importance in the treatment of the illness. The administra- tion of alcohol has by no means so favourable an influence on the course of the disturbance as has always been assumed hitherto. I have treated delirium tremens myself for more than ten years quite without alcohol, and have had every reason to * The patient became clear after the deUrium had lasted six days, and died a few years later without having had any return of the disease. Alcoholic Mental Disturbances 107 be satisfied with the result. To combat the dangerous weakness of the heart, I prefer caffein, camphor, and, under some circum- stances, strophanthus. I have also found warm baths very useful. Of hypnotics I consider paraldehyde the most effective and at the same time the least dangerous. The collectedness and clearness shown by the last patient throughout almost the whole of the delirium, in spite of the most vivid hallucinations, may be said to mark the transition to another and nearly allied form of alcoholic mental disturbance. The agent, aged thirty-five, whom I will show j'ou as an example of this, was sent here from the surgical hospital. The patient has chopped off the terminal joint of his left little finger. He is almost quiet, and is quite collected and clear about time and place. But in a conversation of any length we can clearly perceive a secret apprehension. He says he is not mad, and will not stay here, because, if he does, he will never see his children again. He knows very well that he has been condemned, and will be pur- sued by the police and executed ; the scaffold is up already. He begs for mercy. He suddenly breaks off in the middle of his conversation, listens intently, and declares that he hears voices, which he can distinguish quite plainly. He is telegraphed to through the telegraph apparatus we have in the house. When asked to repeat the words he hears, he does so in a sing-song tone : " Seven oaths — father no perjury — four perjuries — no, two — not quite sure — good people — honourable people — father strangled mother — son good fellow — brother a, brother a — no brother at all— father has strangled mother — because it was not said wife had it with my husband." He goes on talking in this way, as if he were following a telegraphic communication, and then asks quite quietly, " Is it true that my father and mother are dead ?" There was a singing in his ears, and then he felt a blow on his belly as if glass were pressing in. When he coughed, it lose up hot in his head. There is nothing to be heard of hallucinations of sight. To the question how long he has been ill, the patient answers without hesitation, " For three and a half weeks," although he said before that he was well. The voices began then ; they said, " Fresh eggs, good eggs — All's well that ends well — H you don't come to-day, you'll come to-morrow." Everything was asked about ; if he thought anything to himself, the man who was talking to him knew it too. He has not seen him — " of course, he was far io8 Lectures on Clinical Psychiatry away," Others talked about him, but his wife did not notice it at all. Once he heard a voice up in the loft, " O God, if my husband sees that !" He went up with the oven-rake, but could not find anybody. He chopped off his finger because he was told that that would be a test if he had courage enough to be admitted as a freemason. He was hypnotized by a doctor who would now be executed here. His three children had had their throats cut by his wife, and, as the voices told him, she had also stabbed an old man to death. With regard to the development of the illness, we learn that the patient belongs to a healthy family, and that he married eleven years ago, and has four healthy children, while three are dead. He was always rather inconsiderate and extravagant, and had travelled for seven years. He had drunk a great deal since then, and become irritable, rough to his wife, and sexually dissolute. He came home unexpectedly one evening about four weeks ago, and his crazy manner was at once remarked. He ate nothing and could not sleep, complained that he was hypnotized and would be beheaded, and accused his wife of having given herself to other men, and got 20,000 marks for it. His hands trembled strongly. He was restless, answered voices he heard, spcke to himself, expressed ideas of persecution, and threatened those around him. He became more and more apprehensive during the last week, and wanted to cut his throat and drown himself, ran into the water, gave himself several stabs, and was m the act of driving a knife into his forearm, when his wife pre- vented him. Finally he chopped off the end of his finger. The patient himself declares that when he began to hear voices, while he was travelling, he suddenly became very apprehensive, and felt himself driven home. At home the voices had already taken precautions, and reported everything. They told him that he had been hypnotized with a machine by a doctor, who was a thought-reader and was called Wagner, and that his wife had been proclaimed a common prostitute. The patient admits that he has drunk hard ; that cannot be avoided in his occupation. He adds, " When I am well again, I would rather go into the cigar business." To the objection that he is to be executed next day, he replies that he may still be pardoned ; perhaps they will think that they really cannot execute the insane fellow. No physical disturbances can be seen now, except very bad sleep and fine tremors of the outspread fingers. Alcoholic Mental Disturbances 109 The picture of disease before you has a certain resemblance to delirium tremens, in the quickly-developed, fantastic delusions, the vividness of the hallucinations, the remarkable combination of insane ideas with a sense of illness, and the alcoholic origin. It differs from that disease chiefly in its much longer duration, in the absence of any disturbance of the patient's idea of his posi- tion, and in the predominance of hallucinations of hearinr, com- pared with the prevalence of hallucinations of sight in delirium tremens. The unrest, too, is generally less, and the tremors are not nearly so pronounced. For these reasons, it seems best to distinguish this illness from delirium tremens, although the two are certainly nearly related. We call this disease alcoholic mania. Its course may extend over several weeks or even months. The outcome is generally complete recovery,* but there is no inconsiderable number of cases in which incurable states of weakness remain, usually with particular permanent delusions and hallucinations. Those cases more especially seem to take this unfavourable course, in which hallucinations of other senses appear together with those of hearing. Unfor- tunately, the special characteristics of these conditions are not yet perfectly understood. The treatment involves the most careful watching because of the danger of suicide, and also long and complete deprivation of alcohol. If this is not carried out, relapses are certainly to be expected. * Our patient became sane after the disease had lasted six weeks. Now, after eleven years, he does not drink, but lives apart from his wdfe. LECTURE XII INSANITY IN ACUTE DISEASES Gentlemen, — ^The servant-girl, aged thirty, whom I have had brought into the room in bed, will give the impression that she is seriously ill at the very first glance. She lies with sunken features, trembling slightly, responds in no way when she is spoken to, or at the most turns her head a little, and does not speak at all. On urgent persuasion, she slowly puts out her tongue, which is dry, red, and covered with brown crusts, her lips and teeth being covered with sordes. The patient does not obey any other orders, but makes all kinds of uncertain, rubbing move- ments. Her expression is unintelligent and cheerful. Her temperature is rather high, her pulse over lOO, soft, and not dichrotic. The physical examination shows no other perceptible changes, except exaggerated knee-jerks, signs of ankle clonus, and a little albumin in the urine. If we try, on this meagre foundation, to form at least an ap- proximate idea of the nature of her complaint, the patient's severe stitpefaction will be the most important psychical symptom. As she has shown her tongue, it is not probable that her stuporose condition depends on negativism, and we must rather suppose that she takes in and understands what is said to her imperfectly. Neither does there seem to be any impediment in the psycho- motor province, as her independent movements, though showing great weakness, are carried out without difficulty. Indeed, we may conclude that there is slight restlessness. Her mood is neither sad nor apprehensive. Lastly, it is plain that she has some acute physical disease in a severe form, which cannot at present be recognised exactly. If we inquire into the development of the condition and the patient's family history, we learn that her grandfather came to no Insanity in Acute Diseases iii his end by suicide, that her mother is nervous, and that several brothers and sisters died in childhood of convulsions. She was well herself until four days ago, and had only slept badly for two nights before. After having done some house-work in the morning, she complained of great heat at noon, and very quickly fell into a delirious condition, in which she tossed about restlessly in bed, and thought that she would be burned or taken away by the policemen and executed, that she was the wandering Jew, and that people railed against her. She became quieter in the night, but was so excited again next day that she had to be trans- ferred to the hospital. Here she showed the greatest restlessness, rubbed and stroked about on her body, tossed herself this way and that, and twisted her hair, so that an accurate examination was impossible. She did not answer questions, but talked to herself quite incoherently in single, abrupt sentences, bringing in words caught up by chance. One got the impression that the patient had numerous hallucinations of sight and hearing. She did not eat anything, her lips were dry and covered with crusts, and menstruation occurred. The aimless restlessness was very great again during the next night. The patient chattered confusedly to herself, slid about on the floor, threw her legs in the air, knocked on the boards and the beds, pulled out other patients, hit out round her, and let herself fall out of bed. Giddiness and great unsteadiness on her legs were noticed. On the third day of the illness the restlessness continued, but the patient began to answer the questions ad- dressed to her sometimes, though only to return to her confused talking again. She obeyed orders occasionally, and showed her tongue when it was done before her. Her temperature in the evening was about 38-4° C, but could not be taken accurately. During the next night the patient was rather quieter, and talked nonsense to herself in a low tone. Yesterday morning, too, she was quiet, very much dazed, and giddy. She talked in a low tone and confusedly, bringing in single words she caught up. Her temperature was 37-5° C. in the morning and 38-4° C. in the evening, her pulse 132 ; at mid-day she had a thin yellow stool in bed. In the afternoon the patient asked for water, as her tongue was so dry. She said that she had no headache, and that she thought she recognised the doctor, but did not know who he was. Her mood was indifferent, rather changeable, and not predominantly apprehensive; 112 Lectures on Clinical Psychiatry The development of the illness described quite excludes the idea of paralysis, on account of the suddenness with which the delirium broke out ; nor, indeed, is there any other ground for such a supposition. The psychical condition hardly corresponds to that of dementia praecox, which might also be suggested. The severe disturbance of comprehension and the deeply-clouded consciousness are more esp2cially opposed to the idea of this disease, and the patient's talk was neither senseless nor stereo- typed, but only incoherent and delirious, and no signs of stereo- typism, automatic obedience, or negativism have appeared in her behaviour. We could only establish great divertibility rather by outward than by inward incentives. We must also dismiss the possibility of maniacal stupor. As has already been said, there was no impediment in the psychomotor province, but lively excitement and garrulity, with the most severe stupefaction. Now, the impediment of thought in maniacal stupor usually affects comprehension and the course of thought far less, but is associated with impediment of the impulses of the will, including those in the province of speech. The confusion of the patient's remarks was much greater than what is observed in the occasional speech of sufferers from maniacal stupor. Lastly, the extra- ordinary rapidity with which the severe symptoms set in is quite unusual in that disease. Thus, the hypothesis of a post-epileptic or hysterical state of semi-consciousness is the only one left. As regards this, it must first be noticed that there is absolutely no support for the idea of either the one or the other disease in the patient's previous history. Again, the well-defined, apprehen- sive, irritable, or extravagant mood, which we do not usually miss in this condition, is entirely wanting. Neither can we find any definite delirious purport in the patient's talk, as is always the case in those diseases, so far as the patients express their thoughts at all. The confusion is much greater than we could expect, where, as in this case, the patient still understands particular questions correctly, and tries to answer them. In this last respect, the condition of our patient must remind us strongly of the deliriums of certain jehrile states, in which, in the midst of all kinds of incoherent nonsense, it is still possible to get a correct answer by speaking loudly or emphatically. As there is an increase in the temperature, though a slight one, the question must always present itself, whether some severe physical illness does not form the basis of the psychical disturbance. Insanity in Acute Diseases 1 1 3 The severity of the whole picture of disease, the albumin in the urine, the formation of sordes on the tongue and lips, and the great weakness and uncertainty of the patient's movements, give this supposition great support. The slight increase in the tem- perature of itself cannot, of course, produce these disturbances, while the sudden appearance of so severe an illness points with a certain degree of probability to the occurrence of poisoning or toxic infection. The physical signs are at present so ambiguous that it is impossible to be quite certain about the kind of poisoning. We will, however, remember that sudden delirious conditions of this kind are not very infrequently observed at the beginning of small-pox and typhus, and at first may easily be mistaken for other mental disturbances. Small-pox is, upon the whole position of things from the very first, extremely un- likely. On the other hand, we have learned that there have actually been some cases of typhus in the place where our patient has resided. The course of the physical disturbances, too, until now can very well be reconciled with the supposition that this is the beginning of typhus, even if conclusive grounds for the belief cannot be found in it. It seemed to us, however, even at the first examination of the patient, that the diagnosis of a typhoid " initial delirium " was the most probable, on the strength of the considerations adduced. If our conception is correct, the present severe condition will not last very long. Initial delirium generally disappears with the further development of the disease, but may be replaced by ordinary fever delirium, which generally causes much less stupe- faction. But attacks of typhus beginning with initial delirium are, as a rule, extraordinarily severe, so that in more than half of such cases the patients seem to succumb quickly. We must therefore be prepared for such a result in this case.* To guard against it, we must have recourse, besides careful nursing and watching, to special treatment by protracted baths, skilful feeding, and transfusions of common salt. Perhaps we may thus succeed in bringing the patient over this first and most critical period of her illness. Fortunately the other mental disturbances produced by acute •diseases have not the same bad prognostic significance as initial * The patient died early in the tenth day of her illness. Its whole -further course, as well as the post-mortem examination, coincided u-ith ■.those of a severe infectious disease, and more especially of typhus. 114- Lectures on Clinical Psychiatry delirium. Indeed, these and a few other forms are the only kinds of insanity which admit of, and almost always arrive at, complete and permanent recovery, even in the strictest scientific sense. Here I will show you a woman, aged fifty, who sits before you apathetically, but answers questions in a low, tired voice. She knows that she is in a hospital and that we are doctors, but cannot say how long she has been here or how she came here. She has had erysipelas, and " that struck back into her head "; then she was quite confused, and does not know what happened. She says that she heard voices and saw apparitions, but cannot tell us anything more precise about them than that birds flew about. The patient understands with difficulty, has to think a long time even over simple questions about her age and birthday, and the month and day it is, and answers hesitatingly and in mono- syllables, often incorrectly, or at least uncertainly. She does not think she is ill. She does not obey orders until they have been given repeatedly and emphatically. Her mood is rather de- pressed and tearful, but distinctly dull. As to the development of the disease, we know that the woman belongs to a healthy family, and was healthy herself until she came into the hospital three weeks ago with erysipelas. There great heart-weakness suddenly appeared, and at the same time the patient declared that she was dead, refused to eat anything, and had to be fed artificially. After a relapse of the erysipelas, the temperature suddenly fell to 35"8° C. a fortnight ago, and the patient became quite apathetic and confused, and began to have hallucina- tions. The picture the patient now presents cannot be brought into agreement with any of the forms we have studied so far. There is, indeed, a certain resemblance to circular stupor, but the patient's confusion and want of clearness are too great for this, and the severe emotional depression is wanting. Finally, there is not so much an impediment in the psychomotor sphere, which cannot be overcome by any efforts, as a certain atony or indolence. Neither will the picture fit into the frame of dementia praecox. Pronounced confusion and want of clearness are hardly ever found in that disease, except at the very beginning and in association with lively apprehensive fluctuations of feeling, and generally with very marked hallucinations of hearing, about which we can easily learn, owing to the patient's good comprehension. Besides, this, the strangeness of the actions and wishes, which generally Insanity in Acute Diseases 115 gives its peculiar stamp to dementia praecox at all stages of the disease, is entirety wanting m our patient. Hence, even without any knowledge of the previous history of the case, we would not see any of the forms of insanity hitherto described in the clinical condition before us. On the other hand, the signs of psychical enfeehlement which we find present in an equal degree in the spheres of comprehen- sion, thought, memory, emotion, and action, would point to the fact that an injury of a general kind may have occurred, and made its influence felt in all these directions. We would think first of some kind of paralysis, but for this there is no satisfactory support in the entirely negative result of the physical examina- tion. Under these circumstances, we might with some prob- ability advance the hypothesis that there has been an acute physical illness. In reality, we have arrived at this conclusion without any trouble, from the patient's own statements, but I wished to show you that in case of necessity we could have found our own solution without her help. This is important for the following reason : even where there has been a preceding physical illness, it need by no means always be the real cause of the mental disturbance. Indeed, we see often enough that attacks of maniacal-depressive insanity, of dementia praecox, and occasionally even of paralysis, are only suddenly and accidentally developed by a physical illness. In such cases it is of course impossible to infer the occasion which provoked it from the clinical picture, neither can we draw any conclusions as to the further course and the probable result of the mental disturbance from the way in which it began, as we have been able to do with our patient here. If we are sure that the psychosis has been caused by the erysipelas alone, as the special clinical form of the picture of disease shows us here, we may with certainty predict a quick and favourable course for the case.* The treatment must consist essentially of rest in bed and the highest feeding possible. We must probably consider an affection of the cortex, produced by the poison of the disease and gradually passing off again, to be the actual basis of the patient's condition. This supposition is confirmed by the fact that the first psychical disturbances appeared just after the erysipelas had reached its height. Forms * After the disturbance had lasted six weeks the patient became perfectly sane, and has continued so for nine years until now. 8—2 ii6 Lectures on Clinical Psychiatry- such as this are generally included, together with certain clinical pictures of dementia praecox and maniacal-depressive insanitj', under the name of " acute curable dementia." For the reasons I have given, I would rather speak of an infectious state of weak- ness, and would further lay the greatest stress on its being sharply distinguished from stages of other diseases which are very similar to it at the first glance, but are entirely different in their origin, course, and result. In spite of great external differences, the following case is nearly akin to that which we have just discussed. This is the case of a whitewasher, a married man, aged thirty. This physically well-developed patient is only moderately nourished, and has a marked mitral insufficiency, an old swollen gland on the right side of his neck, and a fairly well-healed fracture of the right fore-arm. There are no other physical defects. He is attentive, understands us well, and gives his age and name correctly at once, but does not know exactly when he came here or where he is ; he has heard something said about a lunatic asylum. He gives consecutive information about his business and his past life, but soon gets into a state of some excitement, and begins to lament in a peculiar, incoherent way. He introduces all kinds of recent experiences into his lamentations, such as artificial feeding, expressions used by other patients or by the doctors, and also words and grimaces which he just catches up. " On account of the tube, that must be scarlet-red, like nature, like blood, that they can tear out one's whole sex and put it back again. When they lift up the glass with the indiarubber tube, that lasts a hundred years. I want nothing but home. They want to take off my hands and feet. The time comes rats and mice and everything in the world. Everything comes from the backside. I squeezed them to death ; they came from me ; they say so all together. Our mother and we lived on wild beasts, on snakes and everything, and everything sprang from us. Ha ! when one is done for, one will still fly about so, when the eyes are out and everything is done for, as evil spirits. That is a Japanese, the first doctor. The voices speak as if they were my wife and children. I have seen no one. \i I were out, I would be well, but here they want to take out one's sex. They are in the bath as if they were done for. If one puts down one's shoes, they are gone." The doctors " were very often there, one mostly ; they say they are doctors." He does not know their names exactly. Insanity in Acute Diseases 117 He thinks he has seen one of the audience before, the one " with the blue tie." Here we have first to notice that the patient comprehends particular things quite well — as, for instance, the presence of a Japanese colleague — and that his attention may be diverted by them. It is also always possible to interrupt him at once, and to induce him to enter on other subjects, though he soon digresses again. His understanding of impressions is evidently much dis- turbed. He does not understand his surroundings, and what takes place before him. Although he hears and remembers who we are and where he is, it is not clear to him that the relations of things correspond to the statements made to him. " I cannot understand that," he says himself. Hence everything seems strange, uncomfortable, and enigmatical to him. " I am bewitched," he says. " What silly things are being done there ? Leave off, then, in God's name ! I am to be shaved for ever like the devil ; yet I'm not a devil. Then comes the key ; they show it to me every day. Then the place is unlocked ; there is something missing, and I must have taken it." He is " here in Heidelberg, if it is Heidelberg." With this inability to get a connected understanding of events, and the perplexity which goes with it, hallucinations are also associated. The patient hears voices which he answers ; appar- ently they are reproaches, against which he tries to defend himself, and threats. He is a robber and murderer ; his sexual parts will be torn out. But, side by side with the hallucinations, there is also often a false interpretation of real but misunderstood perceptions. When a handkerchief is mentioned, he asks, " Am I supposed to have taken handkerchiefs too ?" His delusions are all of a depressing character, but they change often, and are not followed up. His mood, too, is downcast and tearful, and some- times despairing and irritable. He has tried to take his own life several times. He obeys orders readily, and puts out his tongue at once, when he is told that it is going to be cut off, though at the same time he pleads that you really cannot do such a thing, and that the tongue is the most sensitive part of the human body. In spite of his apprehension, he is incapable of defending himself, and allows anything to be done with him helplessly, like a child. In the clinical picture before us, together with good comprehen- sion of particular impressions, we see a far-reaching incapacity to connect them and to gain an understanding of the situation I I 8 Lectures on Clinical Psychiatry and of the events taking place, great divertibility with lively attention, hallucinations, depressive, changeable delusions, sad, apprehensive depression, irritability and restlessness, and great weakness r/f will. It is impossible to find a place for this form of illness in any of the mental conditions previously described. The severe disturbance of the understanding and will is incon- sistent with melancholia, while the idea of circular depression is excluded by the great want of clearness in the patient and the nature of the disturbance of his will, which is indicative, not of any impediment, but of incapacity to adapt his action to an end. Lastly, the clinical condition is distinguished from the depression of dementia praecox by the contrast of good attention with bad comprehension of things as a whole, while in that disease there is generally surprisingly good comprehension with little attention. It is also distinguished by the violence of the emotional excite- ment and the simple bewilderment of action, as opposed to the emotional dulness and the negativism, automatic obedience, im- pulsive outbursts, stereot^-'pism, and absurd behaviour of dementia praecox. If we should think of the possibility of general para- lysis, this would be contradicted by the absence of all physical signs, by the patient's mental and emotional activity, in spite of his bewilderment, and by his good memory and judgment of all occurrences in the more remote past. It would seem that the combination presented here of good perception and active attention with bad understanding of im- pressions, divertibility, emotional depression, irritability, excite- ment and helplessness in action is diagnostic of certain forms of insanity appearing after acute physical diseases, whether the basis of the disease is formed by infectious causes or by exhaustion. As a matter of fact, there has been acute disease in the present case — i.e., articular rhciimatism. The patient belongs to a healthy family, except that his father was violently passionate. He was a good scholar and an industrious and temperate work- man. He married at the age of twenty-three, and has three healthy children. At the age of fourteen he had an attack of articular rheumatism. He fell ill again of the same complaint about ten weeks ago, and had a great deal of pain. After four weeks the pain disappeared suddenly, but the patient began to talk in a confused way, expressed ideas of sin and persecution, was very restless, prayed a great deal, was very anxious to get out, and hardly ate or slept at all. I Insanity in Acute Diseases 119 On being admitted to the hospital five weeks ago, the patient was confused, did not know what year it was, or the name of the Emperor, heard voices, particularly those of his wife and children, answered questions slowly and awkwardly, but relevantly, though often incorrectly, and could not do simple sums. His mood was depressed and apprehensive, and echolalia, echopraxis, and catalepsy transitorily appeared. These last disturbances gave rise to a suspicion of dementia praecox at first, but it had to be given up at the first examination, in consideration of the clinical picture as a whole. Indeed, we know that automatic obedience by itself is merely a symptom of a disturbance of the will, which may come under observation in very different forms of insanity. The patient's nutrition was very bad, and has sub- stantially improved since then. At the same time, he has become more active and restless, but is no clearer yet. In this state you have seen him before you to-day. The history or development described here exactly corresponds to our experience elsewhere, and the sudden disappearance of pain in the joints, in particular, on the setting in of the psychical disturbances, has often been observed. Considering the clinical picture, we cannot doubt that the articular rheumatism is the real cause of insanity here. The condition corresponds most clearly to that which, in imitation of Meynert's example, is usually called hallucinatory confusion, or Amentia. But, unfortunately, the same name is given to a number of essentially different and only outwardly similar conditions, belonging for the greater part to dementia praecox, but often to maniacal-depressive insanity, or to yet other diseases. This clinical picture, as we have defined it here, offers us the assured prospect of complete and permanent recovery, while the other forms alluded to do not. When, as in the present case, we really have a disease which is caused by physical illness only, rest in bed, good and careful feeding, pro- longed baths under certain circumstances, and the occasional employment of medicine for inducing sleep or tranquillity, are enough to re-establish the patient in the course of a few months.* * The patient completely recovered after the mental disturbance had lasted four months, and is still well now after five and a half years. t LECTURE XIII VARIETIES OF DELIRIUM Gentlemen-, — From our investigations so far, you have learnt repeatedly that conditions which belong to the same examples of disease can appear extraordinarily different, while pictures which have a quite different clinical signification are often enough very similar. From this we must draw the conclusion that those s\Tnptoms which change in the course of the same disease, and on the other hand return in the same form in different courses of disease, are to be regarded as universal concomitant pheno- mena of mental disturbances, just like fever, pulse acceleration, and pain in physical illnesses. They do not admit of our forming any reliable conclusions upon the particular nature of the malady m question, and from this point of view are to be regarded only as accidental symptoms, be they ever so striking or dangerous. Opposed to these are the distinguishing disturbances, often appar- ently much less significant, but in reality diagnostically essen- tial, which we invariably find in the most diverse cases of the same disease, and which reveal to us, therefore, the nature of the underlying malady. Of course, so far we know only a v^ery small part of the essential symptoms of disease. It might be possible to establish that very many of the disturbances which now appear to come forward in quite similar form in different diseases might yet, by the most minute dissection in the one and in the other case, present certain differences. For example, we now dis- tinguish between maniacal and katatonic-motor excitement, and between impediment of the will and negativism, of which the two first used to be comprehended under the common name of necessity of movement, the two last under the name of stupor. So far as we are already in a position to assign outwardly similar conditions, on the ground of distinguishing peculiarities 1 20 Varieties of Delirium 121 to various kinds of diseases, I have endeavoured up to now to point out to you the goal, and the road to it. To-day we shall also try to find out the distinctive hall-mark in a little group of apparently similar classes of disease, which makes the recogni- tion of the peculiar clinical interpretation of an individual case possible. The strongly-built school-teacher, aged forty, whom I will first show you, lies in bed with rather shrunken features and flushed face. He is in perpetual restlessness, burrows under the bed-clothes, rhythmically rubs about on his arms and legs, searches for and plucks at the coverlet, rolling and turning, while his movements are tremulous and uncertain. The patient does not trouble at all about his surroundmgs, generally does not answer questions, or at the most looks up for a moment ; is quite occupied with himself, talking foolishly in a disjointed and unintelligible way. Only on being spoken to very emphatically is his attention aroused and a few remarks obtained from him, which are at first sensible, but quickly become disconnected. He was twenty-four years old when he was born, son of the Emperor William ; his father is called Germanicus. He is engaged to a most beautiful Jewish girl, but no longer remembers her name. He is here in the infirmary which belongs to him ; sometimes he has the impression that he is rather deranged. The Emperor of Russia has made him a present of two thousand million mines in New Zealand ; they abound in gold. He has to die ; he cannot speak ; he has the sinews of a man-eater, a silver arm, and no longer a lar\'nx. They wanted to tear out his eyes, and were going to put him in a new heart. He has raised con- siderably the height of the surrounding hills ; he can make mice. The patient is divertible, is taken up with any casual impres- sion, and jumps suddenly, at random, from one thought to another. He sees birds flying in the air, speaks of people being outside, who are not to come in ; says he has worked the whole night, and that he has cut the borders from the coverlets. His mood is now cheerful, now irritable and angry. Transitorily he becomes apprehensive, then breaks out into violent abuse . desires that the warders who have to do with him should in- stantly be struck dead or shot to pieces. The picture of disease that we have before us to-day is ob- viously one of delirium. The patient is stupefied, clouded, con- fused, and has hallucinations. Special features of the picture, 122 Lectures on Clinical Psychiatry such as the trembling, the uncertainty of movement, the seeing of flying birds, the cheerful mood, the delirium of occupation, the tossing about and nestling, remind us very much of the alcoholic delirium already described. But we have a series of important deviations to note. Our patient is much more confused than subjects of alcoholic delirium usually are ; he also makes sense- less statements as to his earlier circumstances ; lastly, the ex- ceedingly fantastic delusions which he expresses point to a change of consciousness of personality such as never happens with these patients. On the other hand, the physical examination of the patient at once shows us the right road. We have already noticed in his talk that his speech is slow, indistinct, and slurring. The pupils are unequal and insensible to light ; the sensibility to pain is lowered ; the features are flabby and expressionless ; the tongue is put out tremulously. Great rigidity exists in the legs, which makes it difficult to try the knee-reflex accurately ; but it shows distinctly. We very frequently meet with precisely this appear- ance in paralytics, in whom also the legs cannot be acted on in the usual way. On the sacrum there is a superficial skin-scurf ; on various places on the body we find little furuncular sores. The physical s^Tnptoms prove beyond doubt that we have not to do with a rapid and probably curable delirium tremens, but with a condition which belongs to the course of forms of general paralysis. According to this interpretation, there is nothing remarkable in the patient's absurd ideas of greatness and in- significance, such as his illusionary information as to his age, parentage, and so on. With regard to the development of the malady, we learn that the patient, whose family circumstances are unknown, led earlier a very irregular life, and was very fond of strong drink. All information as to luetic illness is wanting. He was engaged to be married, and lately made every effort to obtain a Government appointment. The illness began quite gradually with headache, sleeplessness, defective appetite, and depression. Then the patient went a great deal to the public- house, drank more than usual, was exceedingly talkative, thrust himself into the foreground, " talked big," gave himself out for a rich man, gave large orders at a jeweller's, and fell into ever-increasing excitement, so that he had to be taken to the infirmary, where he was exceeduigly violent, and from thence he had to be brought to us. He has been here four weeks. Varieties of Delirium 123 As you may see, the development of the disease entirely cor- responds with the diagnosis established by us on the ground of his present condition. Indeed, we also now recognise that the similarity of the description with an alcoholic delirium probably depended on a mixture of paralytic with alcoholic features. Nevertheless, I will remark in passing that similar, if somewhat differently-coloured, delirium also occasionally comes under observation in general paralysis without an alcoholic history. The form of this case of disease under observation is a very severe one ; it corresponds with those which we have mentioned before as acute general paralysis. We must therefore be prepared, even if the possibility of a remission is not to be quite excluded, for a rapidly unfavourable result which might be induced either through an apoplexy, septic pneumonia, or some septic infection.* We are treating the patient with the prolonged bath, which works favourably both for the restlessness and the skin sores. Though he sometimes eagerly takes food himself, yet he sometimes entirely refuses for a long time together, so that artificial feeding is often necessary. If imminent heart weakness threatens, we shall resort to saline transfusions. The next patient whom I will show you, a goldsmith, aged twenty-six, is in such great excitement that he has to be held. He struggles violently on that account, tries to bite, snorts, makes faces, foams, slobbers, seizes his shirt with his teeth, trying to tear out a piece, tries to seizo hold of anything with his hands, clings spasmodically to what he has grasped, twists him- self, and treads with his feet. Persuasion makes apparently no impression at all on him ; he does not look up, gives no answer, obeys no orders, but struggles with all his might and with a defiant expression of countenance to get away from the arms restraining him. Suddenly he begins to bawl, " Hah, hah, hah ! — ^will you make me sweat — that is a right Christ — and the rest shall go out ! All that goes away ! Then I shall hear who comes there. Will you force me — all out, and my thing out that doesn't belong to you, all." Gradually he becomes quieter, so that he can be let free. He now sits upright in bed, the upper part of his body inclined forwards, his arms stretched out at full length, while he nods his head with a smile, quickly moves a cloth as if to strike, tries to tear it, draws it through his mouth, and will not allow it ♦ The patient succumbed seven weeks after admission, as the result of an apoplexy. 124 Lectures on Clinical Psychiatry to be taken away. Then he calls out, " Bring me my money, bring me my blood, bring me my sweat." He snatches the key away from the warder, and shrieks, " Away, who sweats — all away, who sweats 1 Go in there ! That one who has been there and has taken me, remains there — here, ha, no trouble at all !" Then he leans back, stretches out his arms, wraps his hands in the comer of his coat, and remains lying rigidly in that position. If you try to change his position or to take his hand, he at once falls into great rigidity ; if you approach his head, he shrinks it back a little, but allows a needle to be stuck into his forehead without resistance, and does not remove it. He does not say anything more, but once nods his head when he is asked whether he knows the doctor. An accurate physical examination is not possible on account of the patient's resistance. If we would rightly interpret this condition of confused excite- ment, we have in the first place to notice that the perception of the patient presents apparently no disturbance. His efforts to seize and to tear something, also to get free, were so adroit that they were only possible with the most rapid and complete use of the impressions of the senses. That the patient opposes all addresses and orders cannot be attributed to poor comprehension, but only to opposition. But the opposition might perhaps be dependent on delusions or on apprehension. To the first, neither the actions of the patient nor his speech pointed in any tangible way ; in any case, it would be exceedingly difificult to explain the whole strange behaviour from definite delusionary lines of thought. But it also follows from his smile, and especially from his indifference to the needle-sticking, while the gentlest touching of his hand immediately brought on the strongest opposition, that apprehension was not the motive of his actions. It is precisely this last-named circumstance that perhaps makes it clearest to us that here we have to do with symptoms of negativism with instinctive opposition, without foundation from apprehension or illusions. These latter being more frequently absent than present, can consequently in no case form the true reason of negativistic appearances. But, apart from certain conditions of disease in old age as yet little investi- gated, negativism comes under observation virtually only in dementia praecox, though occasionally also in general paralysis. On account of the impossibility of a physical examination, we cannot with entire certainty exclude the latter disease, though Varieties of Delirium 125 the age of the patient makes it very improbable. The great agility of his movements is also contradictory to that assumption. On the other hand, the abrupt alternation between senseless ex- citement and rigid tension, the taking up of peculiar attitudes, and lastly, the high degree of confusion of talk with good compre- hension, the uniform repetition of the same turns of expression, and his meaningless ejaculations, containing no reference to any given circumstances, remind us forcibly of our former experiences of the picture of disease of katatonia. To this also belongs the slobber- ing, since it usually appears with extreme frequency in dementia praecox, either temporarily or permanently. Therefore, with the greatest probability, we must take our patient for katatonic. As to the development of the malady, we must note that the strongly-built patient comes of a healthy family, but from his youth up was always somewhat peculiar. During his military service, which he went through otherwise satisfactorily, a peculiar play of features (grimacing) gave rise to remarks. The present illness began quite gradually about eight weeks ago. After the patient had been very restless and had got up a dozen times during the night, the following night he began to groan and to call out aloud, and threw various articles out of the window. The second day he was angry, spoke at times confusedly, but remembered his behaviour in the night. His excitement now increased very rapidly. He asked whether he would be hanged or beheaded, wished to hang himself up, becoming very violent, threw his mother on the ground, overturned a stove, and at last sprang out of the window, although his hands and feet were fastened, without, however, doing himself serious harm. On admission to the hospital four days later, the patient was quite quiet and entirely clear, but had imperfect remembrance of what had occurred — at least, he hardly spoke at all about it, but also showed no wish to become enlightened as to his experiences and his condition, and took no thought of the future. The almost sudden beginning of the violent, confused excite- ment, accompanied by states of lively apprehension and ideas of persecution, the rapid disappearance of the symptoms of disease, and the very imperfect remembrance of the attack, very much suggested the presumption of post-epileptic mania. But after a more accurate examination we had to reject this assump- tion as improbable, as after the cessation of the excitement, although a distinct weakness of comprehension did not exist, 126 Lectures on Clinical Psychiatry yet the patient was entirely wanting in that clear and complete understanding of the disease which is never absent in the epi- leptic. Epileptic patients, as a rule, perceive with accuracy that from a certain point of time a profound morbid revolution has taken place in them, whose end is indicated by the correction of the delusions and the endeavour to separate the morbid occur- rences as sharply as possible from healthy life. It is only in advanced imbecility that this lucid attitude towards the con- ditions of disease gradually becomes effaced. Moreover, all symptoms on which to found a diagnosis of epilepsy were wanting in our patient's previous history. Therefore we came to the conclusion, at that time, that a katatonic state of excitement had to be dealt with which would be followed by a remission of probably not very long duration. In point of fact, the patient was onl}' four weeks at home, then again became excited, and yesterday was brought back to us in the condition in which you now see him. This time also we may perhaps expect that the excitement will not last very long, and will result in a new remission or in stupor. On the other hand, one can predict with considerable probability that finally, after several intermediate attacks, a more or less marked degree of feebleness of mind and sensibility will remain behind.* The treatment evidently presents great difficulties, as there is no saymg how the patient will not act, and he may at any moment do the greatest violence to himself or to others. He needs, there- fore, the most careful watching, both in bed and in the bath. If the excitement should for a time so increase that the bath treatment becomes impossible, we shall be compelled with the aid of hyoscin to have recourse to regular wet-sheet packings, which in such cases are often of most signal service. The patient very soon becomes accustomed to give up his original resistance. After two hours we release the patient from the pack, but repeat this as required at short intervals until some tranquillity is induced, and the bath treatment resumed. As a rule, this generally occurs after a few days. * The patient so far gradually improved that six months later he was able to return home. Nevertheless, after another six months, he again became excited, and presented as before, with entire rationality, an irregular change between negativistic stupor, unconcern, and instinctive violence, with a tendency to play on words and grimacing. For five years and a half he has remained unchanged in a nursing asylum. Varieties of Delirium 127 The third patient whom you see before you to-day, a cigar- maker, aged thirty-nine, has also to be supervised by several warders. It is true, he lies there quietly for a moment, breathing hurriedly, with rigid, open eyes and large pupils, and does not move if one speaks to him, pinches him, or even touches the cornea. The knee-jerks are exceedingly active. Suddenly the patient springs up, tries to throw himself out of the bed, and begins with senseless violence to fight those nearest him, so that he can only be held with the greatest trouble. Meanwhile he calls out loudly : " Let them out, now it comes, mother, mother — go away ; let them run past ; help, help me — help, come. We go out there, Jesus, Mary — let them pass, Katie ; come, take me to you, Katie." He repeats the last words many times. Gradually he becomes quieter, murmurs low to himself, sinks back, and now lies motionless as before. After five or ten minutes the excite- ment recurs with a sudden springing up. From the patient's broken sentences we can make out the following : " Don't go so near, you will fall in ; throw him something. What are you putting in there ? I shut the barrier again. We don't go out, it won't do. You bulldog, get away ! the nasty brute. Fritz, put to (harness), or I will throttle you. Throw him away, squeeze him, till he has had enough. The nasty brute sets the dog on me." With signs of the most terrified apprehension, he goes on : " Grandmother, the red witch, still laughs ; Fritz, now he brings his lads with him. Now they lay hold of me by my new coat, Hermann. Go a flight of stairs higher ; it is not I. Let me go ; I must go to the factory, Theresa "; and so on. This change from excitement to lying in stupor repeats itself over and over again. Even in the excitements it is impossible to obtain any answer or reaction from the patient when addressed. In spite of many outward similarities, this patient is at once distinguished from the former one by the fact that he is very stupefied. His assaults are made with great violence, but quite without the adroitness and finesse which we observed in the other patient. As the patient does not react to any outward stimulus, we have no cause to assume that he is negativistic, especially as in the pauses he sometimes allows his arms to be moved without any will of his own. On the other hand, the patient's talk is certainly disconnected, but comprehensible throughout. One easily sees that he lives in a dream-world with changing incidents, with which his utterances accord. Lastly, there exist markedly 128 Lectures on Clinical Psvchiatry in him very severe fluctuations of emotion, especially of an appre- hensive kind, when he believes himself to be surrounded by dangers making him defend his life. The condition is therefore evidently one of delirium. Of the varieties of delirium that we have hitherto considered, the alcoholic would from the first be excluded on account of the profound stupefaction, and from the want of the peculiar kind of unrest as well as of the tremors. Also, the clouding of con- sciousness is too deep for an ordinary' fever delirium ; this also, along with the want of the symptomatic disturbances of will, contradicts the assumption of a kata tonic state of excitement. Certainly, the constant repetitions of the same ejaculations might be construed as katatonic stereotypism ; I might observe, however, that we have to deal with ejaculations which, according to their purport, form the expression of apprehensive states of mind. Their repetition, therefore, is very well explained by the lively apprehension itself, without our having any reason to assume an aimless instinctive compulsory force. In a paralytic delirium, or in the initial delirium of typhus, we certainly meet with profound stupefaction, yet in neither of those cases should we be able, even in a small degree, to follow the purport of the V'Cry confused delirium. In both of these conditions the outward perception is less disturbed and the delirium far more incoherent than in this case. Also, the movements of our patient are of greater strength and force than we should expect to meet with in those two conditions. But, lastly, the case under consideration, with its profound disturbance of comprehension, its active delirium, its extreme apprehension, the inclination to reckless acts of violence, and the change from stupor to suddenly recurring excitement, abso- lutely corresponds with that of certain epileptic semi-conscious conditions. The large immobile pupils are also in favour of this assumption. We may therefore expect that after a quite short time, probably after a few days or hours, tranquillity, lucidity, and insight into the illness will set in, without clear remembrance of the present occurrences, but that sooner or later similar phenomena will be repeated. Under these circumstances, the treatment can be reduced to strict supervision of the patient, whom we have placed in a padded bed. If we now look back upon the previous history of the patient, to see whether further support can be discovered for our inter- 1 Varieties of Delirium 129 pretation, we learn that a brother of his mother's was insane. He himself was run over at nine years old, and was at that time for some days unconscious. Latterly he has for long drunk pretty deeply, though he could not stand much. Till his fourth year he suffered from infantile convulsions and wetting the bed. At school slight attacks of giddiness often still came on, but he learnt quite easily. Later on, too, he was often very giddy in the morning. In his thirty-fourth year a condition in connec- tion with abuse of alcohol came on for the first time, in which he was delirious, expressed ideas of grandeur, did not know where he was, and only came to himself after eight days in a hospital for the treatment of the insane. At that time he led a very unsteady life. It frequently drove him away from his work without any definite reason, so that he left everything to chance, even money due to him, and went out haphazard into the world. The semi-conscious conditions were repeated several times, and led him into various asylums. In such a condition he came to us about four weeks ago, but soon became lucid again. Some days after admission a fresh attack of similar kind set in, and afterwards the patient was low-spirited during the whole day. The attack quite resembled the present one. After three hours' duration of the attack, the patient fell into a deep sleep, from which he awoke next morning without remembrance of what had happened. The repeated depressions, very well described by the patient himself, were very pronounced. He felt "as if he had a terrific ' next-morning headache,' and was obliged, without any reason, to stare into a corner, and wish that someone would put him to death ; life had no longer any value for him." Anxiety to get away was also observed in these conditions. It was all over after one or two days. Such states of ill-temper regularly preceded the states of semi-consciousness which set in •quite suddenly. The most trivial cause could then put him into the most violent rage. As you will see, this previous history quite corresponds with our expectations. It is true that real epileptic attacks of con- vulsions appeared only in earliest childhood. Later on there were ■only attacks of giddiness, but exceedingly symptomatic bad temper and semi-conscious conditions of a much more severe kind were especially observed, their appearance being promoted through indulgence in alcohol. The regular return of these con- •ditions, the deep obfuscation resulting from it, its rapid ending, 9 130 Lectures on Clinical Psychiatry and the want of remembrance afterwards, leave not the smallest doubt as to the epileptic nature of these attacks, even if we do not allow the not less characteristic bad temper to count as sure proof of the existence of epilepsy. The illness evidently goes back to early childhood ; the accident in the ninth year is hardly to be looked upon, as one might at first think, as the cause of the malady which most probably existed previously. In spite of this long duration of illness, the patient is, however, not imbecile worth mentioning. Certainly he shows the pedantry, the sensitive- ness, and the outward piety of the epileptic, but is possessed of quite fair knowledge, moderately good judgment, and the inclina- tion to occupy himself not only physically, but also mentally. But for all that, on account of the danger to himself and his neighbours, permanent residence in an asylum is hardly to be avoided.* * For the last four years the patient has remained unchanged m a nursing asylum. He is often depressed, but has had no convulsive attacks, and works industriously. LECTURE XIV PUERPERAL INSANITY Gentlemen, — The revolutions brought about in the physical economy of women by the different stages of the work of repro- duction are so far-reaching that they cannot but influence the course of mental disturbances. As a matter of fact, we see psychical illness developed in the puerperal state in about 7 per cent, of the women admitted to asylums, and rather less frequently during pregnancy or lactation. We have repeatedly come across such cases in the course of these lectures. But experience shows that all the observations of this kind are not of equal value. People very often speak of " puerperal mania " in the sense of a particular form of insanity produced exclusively by the puerperium, but this view can only be maintained to-day within very narrow limits. Where mania really appears in the puerperal state, it is, like every other kind of mania, only a link in the chain of attacks of maniacal-depressive insanit}-. The puerperium cannot therefore be regarded as the cause, but only as the last impulse to the outbreak of the disease. Accordingly, we must be prepared for the occurrence of further attacks after some other provocation, or even without provocation. As a rule, however, the pictures of disease which develop in the puerperal state are not maniacal at all, but are essentially different from maniacal attacks even when they resemble them outwardly. Among these conditions, katatonic states of excitement are par- ticularly common. An example of illness setting in during pregnancy is offered by a woman aged twenty-nine, who was confined here a year ago. The patient is of medium height and ill-nourished. Her com- plexion is sallow, and there is bluish discoloration of the lips, hands, and feel. The tip of her nose and her toes and fingers 131 9—2 132 Lectures on Clinical Psychiatry are very cold. Her expression is peculiarly strained ; you can see deep transverse lines on her forehead, and her eyebrows are drawn together. The patient, who has to be led into the room, gives hardly any answer to questions, but shakes her head as if she did not understand them. After a little persuasion, however, we elicit some brief and monosyllabic statements about her name and birthday and the names of her children, made almost in a whisper. She often repeats a question before she answers it. While she is being questioned she gets up, goes to the window and looks out, and mentions half aloud the name of a man she knows who happens to be passing. Except for this, she takes very little heed of her surroundings, and looks straight in front of her, without even glancing up when she is spoken to. She obeys orders hesitatingly, and stops now and then while she is carrying them out. In giving her hand, she only touches the tips of my fingers indolently, and then draws it back. If we hold her hand tightly, we notice a certain degree of tension, which can be overcome by a little force. If this is done, the patient shows evident catalepsy. After orders repeatedly and emphatically given, she gets up slowly, goes to the blackboard, and writes the name of her 3-oungest child. She also adds up numbers of two places quite correctly and comparatively quickly. The patient's emotional state shows no definite bias. She is neither cheerful nor sad, nor is she apprehensive. You can stick a needle in her forehead or eyelid without her making any active defensive movement. She only pulls it out slowly, and lays it on the table again. Neither her behaviour nor her expression shows any interest in what goes on around her ; she only twists her face for a moment into an imbecile smile at a jocular remark which she understands. When left to herself, she gently murmurs almost incomprehensible sentences, accompanying them with monotonous rocking movements of her body and arms. " They have done for me — they ought to make a poem — I must go 3'onder," and the like. She repeats these expressions several times, but, in spite of the most pressing inquiries, she will give no explanation of them ; at the most, she shakes her head. Once she goes to the door and murmurs, " I want to go out," but does not go away when the door is opened for her. She shuts it again, and only repeats, " I must go out," pushing against it regularly with her knee. Lastly, the copious production of viscous, ill-smelling saliva, which she empties out on to the floor Puerperal Insanity 133 from time to time without any consideration, is very remarkable. No other physical disturbance can be discovered. The patient's whole attitude leaves no doubt that she is demented. She is able to recognise an acquaintance at once, and to do sums quickly and correctly, but cannot give the least in- formation about her condition or judge of her position at all. There is therefore no question of dimming of consciousness, but of real dementia. This view is supported by her want of all interest in what passes around her and of all emotional activity. The key to a better understanding of her condition is afforded by the signs of negativism — the head-shaking, the rigidity of the limbs, the inaccessibility, the refusal of information, the hesi- tating voluntary actions, and shutting the open door in spite of the wish to go away — the automatic obedience, the stereotypism in movement and speech, and finally the flow of saliva. All these symptoms are indications of the katatonic state of disease with which we are acquainted already, so that we may un- hesitatingly attribute this case also to the same form of insanity. It is true, and I must admit, that we took another view at first. I have already told you that there are states of mental weakness which have been described as " acute dementia," and, unlike ordinary feeblemindedness, are curable. It is supposed that these are cases of cortical changes, involving a fundamental degradation of all the psychical activities, without precluding recovery. We thought at first that we had such a case of acute dementia before us. But I have become more and more con- vinced in the course of time that most of the cases which are called acute dementia belong to the province of katatonia, and some of them to that of maniacal-depressive insanity. The rest are infectious states of weakness, which of course claim a special clinical position of their own. Under these circumstances, I now consider the diagnosis as acute dementia to be quite superseded, and I have abandoned it in the case before us. As a matter of fact, the further development of the clinical condition has given no cause for making any other diagnosis than that of katatonia. As to the previous history of the case, I must now tell you that our patient's father suffered from epilepsy. She was mentally and physically well constituted herself, married four years ago, and had an apoplectic fit three years ago during her first pregnancy, as the result of which she was paralyzed on the right side for three months, but did not have her speech 1 34 Lectures on Clinical Psychiatry affected. The child was stillborn in the seventh month. A second child died of convulsions when nine months old. The present mental disturbance began in the last stage of the patient's third pregnancy. She left off speaking, took no natural interest in anything, and wanted to run out of the house. At the same time she expressed apprehension, thought people wished to kill her, and heard voices calling her. She made all kinds of extra- ordinary movements, ate and slept badly, and finally became quite dumb. When admitted to the hospital a year ago, she was collected, but gave hardly any information, lay in bed apathetically and without any variation of feeling, obeyed simple orders promptly, and showed pronounced waxen flexibility. On the third day a boy was born without difficulty at the full time. The patient was quite indifferent to this, denied afterwards that she had had a child, and took no interest in it. In the next few weeks she became almost entirely stuporose, and then gradually grew rather excited. She ran about the place, tried senselessly to get out, and undressed herself. She also refused food, began to slobber, became dirty in her habits, stood all day at the door till her feet swelled, and pushed at it rhythmically with her knee, but did not go out when it was opened. She would give no information at all. She remembered the birth of the child quite well, and knew its name, but was quite mute when her relations visited her, declaring afterwards that she had not known what to say. An attempt to take the patient back into her family was a failure, as there, too, her habits were dirty and she tried to escape. Her weight, which had gradually sunk after the birth of the child, has increased again a little in the last few months, but without any improvement in her general condition.* The appearance of katatonia during pregnancy is always so common that it is not very probable that it is an accidental coincidence. We must rather suppose that pregnancy, like the puerperium, is very favourable to the development of the disease. It seems to me to be the stuporose forms, quickly passing into profound dementia, which most readily appear, without there being as yet any satisfactory grounds for speaking of a particular " insanity of pregnancy." Parturition has either no influence on the course of the disease, or an unfavourable one. This is an * The patient has now been eight years in a nursing asylum, completely demented. Puerperal Insanity 135 observation of great importance, because it will keep us from inducing artificial abortion or premature birth in such cases — a measure which in reality is never indicated here. The apoplectic fit the patient had during her former pregnancy is very well worth our attention. It is naturally difhcult to decide if it is connected with the katatonia, but I know several other cases where there have been similar attacks in the course of katatonia followed by paralysis, from which the patient afterwards recovered. An entirely different picture is presented by the architect's wife, aged forty-one, whom I am now having carried into the room in bed. This very pale and ill-nourished patient is in a state of continual unrest. She claps her hands, exposes herself, tries to jump up, rolls in her bed, plucks at the pillows and sheets, throws herself about, and suddenly tears up her nightgown and throws away the shreds. Meanwhile she chatters and sings almost incessantly in a quite confused way, often in rhymes and assonances : " Good-morning, Mr. Privy Councillor ; how goes it ? how is it ? [Wie geht es, wie steht es ?] I was never so merry before as I am to-day — my dear Katie [Kathchen] — my dear Maggie [Gretchen], my dear girl [Madchen] — what does that — there you are, my treasure — my husband is a scamp — he is dead," and so on. She speaks of St. Bartholomew's night, of crowns of thorns and nailing to the cross, of war, of spirits that beckon to her, and of men going past. The patient is senseless, mistakes people, and gives hardly any answer to questions ; only now and then she takes up what she hears, and distorts it or gives it a playful turn. Her mood is excited, but changeable ; erotic tendencies find vent in irritability and outbursts of violence. Her features are sunken, her tongue and lips are dry, covered with sordes, and cracked. The patient refuses fluids offered to her, or spits them out again. Her hands tremble strongly, but otherwise, except for the signs of recent parturition, no physical disturbances can be pointed out. This state of excitement reminds us in its essential features of the description of mania. But the disturbance of comprehension and the clouding of consciousness seem to be much more pro- nounced. The confusion, too, in speech and action is sur- prisingly great compared with the degree of excitement. Then there are the delirious hallucinations, of which we see occasional indications in the patient's talk. It seems as if we would be right in regarding this kind of excitement, in which severe dis- 136 Lectures on Clinical Psychiatry turhance of comprehension and thought is combined with compara- tively slight psychomotor excitement, as the manifestation of a course of disease which does not belong to maniacal-depressive insanity, but is produced by exhausting causes. Hence, we see it appear more especially in the puerperal state, also after great loss of blood, and, lastly, after certain very acute inflammatory diseases, particularly pneumonia and erysipelas. The very favour- able prognosis is an essential feature of this form of insanity. So far as we know at present, complete and permanent recovery always results if the patient can be kept alive long enough. In our present case we may therefore hope, on the strength of the clinical history, for complete recovery from the present disturb- ance, in spite of its severity, without our having to fear any subsequent relapses, unless the effect of some new and very in- jurious influence should appear. The patient, whose sister also suffered from mental derange- ment during a confinement, was a highly-gifted, active woman, and has only been married three years. She bore a child seven- teen days ago. She was very much excited during her pregnancy, and had a great deal of trouble over it. When a little fever set in after the child was born, she became very restless and could not sleep, although her temperature soon fell again under the influ- ence of douching. On the sixth day of her confinement she became quite confused, heard voices, saw pictures, mistook people, and did not know where she was. She began to sing and scream, and was brought to the hospital on account of her rapidly increasing excitement. The peculiar form of the disturbance in this case shows that its connection with the puerperal state should very probably be considered a close one. This is not an attack of a disease like maniacal-depressive insanity, which might break out another time without any similar cause, but we may regard the injury caused by the confinement, which has taken place late in the life of this woman, who is no longer young, as the real cause of the mental illness. A prominent part is usually ascribed to exhaus- tion, but there are authorities who lay the principal stress on a preceding infection — that is, on sepsis with fever. In the case before us the appearance of fever would support the latter con- ception, yet the illness during the confinement was only slight, and cases of puerperal insanity occur without any sign of infection. These, however, are usually cases of katatonia. The Puerperal Insanity i 37 question has not yet been really cleared up, but we may point out that, even when there has been exhaustion, sepsis, though of another kind, must also be taken into consideration. Two kinds of insanity of exhaustion are distinguished in accordance with their clinical course : (i) Delirium of collapse, with its very quickly and stormily passing course ; and (2) acute bewilderment, or amentia, which usually continues for several months. At present the first form seems to me to be the best- grounded clinically, and we may regard the case before us, with its extremely rapid commencement and its very severe dis- turbances, as an example of this class of disease. If this view be correct, we may hope for rapid and complete recovery after a course lasting only a week, or at most a fortnight, even though slight excitability and various changes of mood may remain for some time longer.* Recollection of the stormy period is not usually at all distinct. The doctor's task consists in very careful nursing and in keeping up the patient's strength. The right place for our patient is undoubtedly the prolonged bath, night and day, if possible. At the same time, generous feeding is required, which often necessitates the use of the tube on account of the patient's bewildered resistance. Alcohol may be added to the food to obtain tranquillity, and under some circumstances paraldehyde or trional. The slightly impaired action of the heart needs special watching. We strengthen it by the addition of strophanthus to the food, by injections of cocaine, or, in case of serious danger, by saline transfusions, which often have the effect of actually saving life. We have already used them in our present case with excellent results ; the action of the heart is so good at the present moment that we may look on the patient as out -of danger. The whole state of things is far more complicated in the case of a woman of twenty-nine, who was confined two months ago, and has now been five days in the hospital. The patient, whom * The patient became quiet and clear on the twelfth day of her illness, recovered very quickly, and remained perfectlv well for eleven years, but then fell ill of severe phlebitis after an operation for hernia, which led to death from the extreme formation of thrombi. In the last fortnight of her illness severe delirious restlessness with hallucinations, ideas of per- secution, flight of ideas, divertibility and marked fluctuations of mood, were associated with rapid loss of strength and a moderate rise of temperature. This condition may be interpreted in the same way as before. 138 Lectures on Clinical Psychiatry I am also obliged to have brought here in bed, shows active rest- lessness. Arms, legs, and head are continually making jerking, aimless movements, which you immediately recognise as sugges- tive of chorea. The patient makes faces, twists her mouth, wrinkles her nose, shoots out her tongue, and snaps with her mouth. She rolls her head, pushes it back into the pillows, throws herself about, tosses her arms, and makes convulsive movements of pronation and supination. She often exposes herself involuntarily, and does not think of covering herself again. As she knocks herself about ruthlessly in this restlessness, she is covered all over with bruises. The patient's attention is difficult to hold. Now and then she answers a question quickly, but she is quite incapable of giving connected information, and is easily diverted by chance impressions. Sometimes she pays absolutely no attention to what goes on around her. There seem to be occasional hallucinations of sight and hearing. The patient suddenly points with her finger, and says, " The King, the Emperor, who has screamed so there," or she names her brother, whom she thinks she has heard calling her. She is almost clear about her position and surroundings, but brings many events into delusionary connection with herself, and thinks that it is her fault that a fellow-patient is fed with the tube. Her mood shows no distinct colouring, but is rather cheerful than otherwise. From time to time the patient sings, yet she has a clear sense of illness. Her speech is abrupt and gushing, her talk is monotonous, nonsensical, incoherent, and interspersed with expletives relating to nothing : " For instance," " To what extent, then ?" " I say nothing at all," " Red hearts meets no golden hearts. Shall I, then, always give away a golden heart ? Fie, devil, once more ! Golden hearts meet, living hearts meet, dead do not. One gets different hearts," and so on. Sometimes she makes inarticulate sounds. When we let the patient get up, you see that her walk is unsteady and giddy ; she simply lets herself fall, even on her face. The sensibility of the skin is increased, and the patient screams out loudly if you touch her with the point of a needle unexpectedly. Her state of nutrition is very bad, and her weight has sunk nearly 3 kilogrammes in five days. Her lips and tongue are dry and cracked. Her temperature is 39-1° C. The pulse is small, 120 ; the heart is somewhat displaced towards the left. At the apex of the heart a presystolic murmur may be heard. Puerperal Insanity 139 No other physical disturbances can be noticed, except that incipient superficial cellulitis of the left leg might come under consideration as the cause of the fever. The most striking feature of the case is afforded by the choreic movements. Unfortunately, their clinical meaning is not quite clear. They may either be symptoms of a special disease, or accompaniments of hysteria. The severity of the whole condi- tion and the signs of heart failure, which is kno\\Ti to be closely connected with chorea, would rather confirm the former concep- tion. We learn that the patient, whose father died of an apoplectic attack, has suffered since her fifteenth year from attacks of un- consciousness, in which she gave a shriek, twitched her hands and feet, foamed at the mouth, and breathed heavily. These recurred on an average every six or eight weeks. She knew nothing afterwards of what had happened. She did not injure herself, except once when she bit her tongue slightly. The attacks lasted from five to ten minutes. The patient was tired after them, and slept for some hours. When she was twenty-one years old they ceased for three years, but then returned with greater frequency. Three years ago the patient married, having already had an illegitimate child. The attacks ceased again during her preg- nancy. After her marriage the patient aborted twice in four months, then she fell ill two years ago of articular rheumatism. Six months later she was quite confused for four weeks, spoke very little and incoherently, mistook people, lay rigid, had to be fed, and was dirty in her habits. She had no recollection of this condition afterwards. With the beginning of another pregnancy last year the attacks ceased again, and have only reappeared during the last few months. Three months ago a confused state of excitement set in, just like the present attack, but slighter, disappearing in three weeks. A few weeks after her last confine- ment the patient was again attacked by articular rheumatism with fever, which soon disappeared with appropriate treatment. The choreic movements, with bewilderment and mistaking of people, were noticed twelve days ago. They were only slight at first, with occasional improvements, but then grew worse and worse. Even on the patient's admission to the hospital, the disturbances were not nearly so pronounced as now. The pain in the joints had apparently ceased altogether then. When we examine this history, it seems most probable, in view of the regular advance of the illness for years, of the nature of 140 Lectures on Clinical Psychiatry the attacks, especially their uniformity and the patient's biting her tongue, and, lastly, of the absence of other hysterical seizures, that our patient is suffering from epilepsy, and not from hysteria. In this case we should have to deal with real chorea, of which the articular rheumatism that has attacked the patient twice must be considered to be the cause. It is well known that chorea very often follows this illness. It is true that the first attack of chorea preceded the last attack of articular rheumatism, but the valvular heart disease seems to be the connecting-link between the two affections, and may possibly have existed ever since the first attack of rheumatism. As a matter of fact, the clinical picture our patient presents agrees completely with the mental disturbances observed in chorea. Senselessness and bewilderment with choreic move- ments, occasional hallucinations, a morbidly cheerful mood and great restlessness, with rapid physical sinking, are particularly diagnostic of this form of insanity. It is only remarkable that the psychical illness of eighteen months ago presented an entirely different picture. It will, of course, hardly be possible to form a reliable opinion now on the patient's condition at that time merely from the description given by her relations, yet all its features seem to me to show that it was simply one of epileptic semi-consciousness, having no immediate connection with the present illness. If this be so, we will have to distinguish the epilepsy, with its special morbid s\Tnptoms, from the choreic insanity in its dependence on the articular rheumatism. The confinement, to which one might have been inclined to ascribe a leading part in the production of the mental disturbance, seems in reality to stand in no kind of causal relation to it. The case before us is thus a good example of the difference between real and apparent causes, the neglect of which has so often been fatal in psychiatry as well as in medicine. Reproduction in women certainly has an intimate causal relation to katatonia, although the actual point of attack of this subversive influence is quite unknown. Some such subtle connection is also very probable in the case of the delirium of collapse. But where mania or paralysis follows a confinement, we can at the most regard the physical injury as provoking a disease already latent in the patient. In the case before us even such a remote influence on the outbreak of in- sanity can hardly be established. I think that all these dis- Puerperal Insanity 141 tinctions are clearly stamped on the clinical form of the mental disturbance. By careful attention to all the features of the disease, we can very well decide from the illness itself what part the work of reproduction has played in the chain of cause and effect. If the patient does not succumb to exhaustion, choreic in- sanity usually takes a favourable course, and ends in complete recovery.* In the case before us our task will be to keep the patient as quiet as possible, to feed her well, and to guard against infection. Presently we will try to combat the chorea itself by the administration of salipyrin. We are treating the patient with the prolonged bath, and try to give her as much fluid food as possible. The cellulitis will be treated in accordance with the ordinary principles of surgery. * The patient recovered after the disturbance had lasted five weeks. A year later delirium and chorea, lasting for several weeks, again appeared after a number of attacks had occurred in close succession. Since then the patient has been five times in the hospital in the course of three years on account of delirious conditions. The first time there were still traces of chorea, but they have not been observed again. The epileptic attacks permanently occurred about every fortnight, in groups, and were often* accompanied by slight bewilderment. The patient's mental capacity gradually deteriorated. LECTURE XV PARANOIA, OR PROGRESSIVE SYSTEMATIZED INSANITY Gentlemen, — Among the s^Tnptoms of insanity, delusions and hallucinations, very often associated with each other, have in particular attracted attention, along with the fluctuations of mood. The different forms of delusion — the delusion of greatness and insignificance, the delusion of sin, the physical delusion of persecution, and so on — have often been considered as character- istics of distinct forms of disease. According to our present experience, conclusions as to the clinical meaning of a picture of disease from the existence and purport of thfe delusions are only permissible to a very limited extent. The tendencies of human fears and wishes can follow the same morbid ways in the most varied forms of insanity. But yet, the nature of the disease remains naturally not quite without influence upon the form of the delusion. In the following lectures we shall have, therefore, somewhat more minutely to observe some relations of this disturbance to definite forms of disease. The stately gentleman, aged sixty- two, who presents himself before us with a certain courtly dignity, with his carefully-tended moustaches, his eye-glasses, and his well-fitting if perhaps some- what shabby attire, gives quite the impression of a man of the world. He is somewhat testy at first because he has to allow himself to be questioned before the young gentlemen, but soon enters into a long, connected conversation in a quiet and positive manner. We learn from him that as a young man he went to America, and there went through many vicissitudes, finally settling in Quito, where as a merchant he made a small fortune. With this he returned home twenty-one years ago, but on the dissolving of his business connections he was done out of con- siderable sums. At home he lived at first on his money, spending 142 Progressive Systematized Insanity 143 his time in amusements, reading the newspaper, playing billiards, going for walks, and sitting about in cafes. At the same time he occupied himself with all sorts of schemes from which he hoped for recognition and profit. Thus, he submitted to the leading Minister the plan (with a map) whereby Germany could lay claim to a lot of still unpossessed land, especially in Africa and New Guinea, and, above all, the islands of Galapagos, which the State of Ecuador would willingly hand over, and which would become of great importance after the finishing of the Panama Canal. A short time after that same Minister travelled to Berlin, and now began the German Colonial Policy, without, it must be confessed, due thanks falling to the lot of the real originator, which another nation would not have withheld. Then our patient drew up a plan for the cultivation of cinchona and cacao in our colonies ; he also made several inventions for the better connection of railway-metals, by which the jolting, an important cause of de- railment, would be done away with. Finally, he applied for a number of situations which seemed suited to him, including that of the consulship at Quito, but had always only failures to record. As he considered it beneath his dignity to come down from his former greatness, he gradually used up his means ; besides, according to his opinion, there was always something amiss with .the administration of the same. However, on the whole, he did not trouble himself much about it, for he was convinced that a man of his capability and knowledge, who spoke three foreign languages and had been all over the world, had merely to stretch out his hand to find a satisfactory post, according to his preten- sions. ' Nevertheless, he finally fell into embarrassment, for he could not recover his debts in America, so that he was no longer in a position to pay for his maintenance, but had to refer people to his prospective income, which assuredly could not fail still to come in. He was enticed into a district asylum, under the false pretext that he would be given a post, and there he assisted in the management till it became evident to him that they had no intention of paying him for his services. When, on that account, he tried hard for other situations, they sent him, also under false pretences, to the hospital, where he is now illegally detained. That, he concluded with bitterness, was the thanks which the Fatherland bestowed upon him for his services. The patient gives all these detailed explanations in a perfectly 144 Lectures on Clinical Psychiatry- quiet and consecutive manner, and they agree in general with the actual occurrences. What strikes one at first is only an exalted self-esteem and the overrating of his own services and capabilities. It can be seen from the manner of this statement that the patient has not had much education. Further noteworthy is the matter- of-course way in which he assumes an inner connection between his interview with the Minister and the inauguration of the German Colonial Policy, as well as the confidence with which he has, in spite of every failure, lived recklessly and spent his means, and expects even now honour and profit from his activity. If one points out to him the contrariety between his hopes and the reality, he says, " A prophet is not without honour save in his own country "; he was much too clever for the gentlemen. But at last, with a contemptuous movement of the hands, he throws out the remark, " WTiat do you wish ? — the petticoat !" Upon closer questioning, he at first refuses to explain this remark, but then relates, little by little, that a woman whom he calls by the nickname of Bulldog, and who was the daughter of the English Consul at Quito, had persecuted him for twenty-three or twenty- four years with her plans of marriage, and sought in every way to cross his steps in order to reduce him to submission. Even in America things ultimately never went as he wished, and a hundred stuffed birds had, out of spite, been stolen from him by means of a skeleton key ; everywhere he noticed the frauds of the Bulldog and her accomplices. " If people do everything differently from what I should have wished, there must be something more than meets the eye." The half-crazy American also travelled home after him, had insinuated herself into his neighbourhood, had the impudence to dress herself up in man's clothes, and to force marriage by preventing him from finding a post, and by these means brought him to want. This artful person had approached him under various names, though he had always told her that one did not win a man's love through such chicanery. He would perhaps be one of the richest men in California if the Bulldog had not prevented it. She was also to blame for his being brought to the asylum. " Who else, then, could it possibly be ?" Both at home and abroad he was eternally meeting her. He had discovered holes in his boots and stains on his clothes, which could not possibly have been caused except through the Bulldog. All objections that one raises to these ideas are received by the patient in a superior, incredulous manner, and glance off from his Progressive Systematized Insanity 145 steadfast conviction without leaving the slightest impression. One can see that he does not for a moment believe in the seriousness of our remonstrances, but his idea is that we wish to persuade him out of the matter, contrary to our real belief. The most substantial mental disturbances to be perceived in our patient, whose comprehension, memory, and outward bearing allow of no sort of irregularity being recognised, are, on the one hand, his ideas of grievances, and on the other hand his strong over-self-appreciation. The first especially unquestionably wear the characteristics of delusion. They contradict every reasonable experience, are not at all accurately established by the patient, and yet are adhered to with the most extreme tenacity. As it would appear, they have already existed for over twenty years in approximately the same form, and have, in their turn, con- tinually led to delusionary interpretations of the events of life. All small vexations, and, finally, his being brought to the asylum, are referred, not to the natural course of events, but to the deliberate dealings of a certain person and her accomplices. The patient has also, to a certain degree, formed for himself a delusionary view of the world, from which standpoint he works up new experiences. And so it is that the persecution becomes more and more fantastic. Ever-widening circles of his surroundings are to be found side by side with the Bulldog, and we too are on the point of sharing the fate of all who are obliged in any way to act in opposition to the wishes of the patient. So far as can be ascertained, true hallucinations play no part, or only a very trifling one, in the development of the delusion. Certainly, on one occasion, as the patient was passing by a house, he observed that from behind the half-closed shutters a one- year conscript, with a gun, took aim at him. At the same moment a voice called out, " Don't you see that someone is shooting at you ?" After a second warning, when in stumbling lie lost his hat, he noticed that a grazing shot scratched his left temple, so that blood flowed. Then he found the occupier of the house standing close to him with a knife in his hand, a lawyer who was ill-disposed towards him, and who called out that he wished to put his mark on him, as he had offended his wife. As the patient surmised, the man, in order to hide his guilt, wanted quickly to replace by another the hat with the bullet-hole in it, and to disfigure the face of the. corpse he expected to find beyond 10 146 Lectures on Clinical Psychiatry all recognition. How far illusions or delusionary interpreta- tions of harmless occurrences are involved in this narrative it is impossible to say. I might, however, at the same time remark that such experiences are sometimes entirely invented, though they seem to the patient to be real recollections. In any case, hallucinations are not otherwise to be established in our patient. His ideas of persecution are much more connected throughout with indifferent 01 ambiguous real events, to which he alone gives their special construction, such as the holes in his boots, his being brought to the asylum, and his unsuccessful applications. In this delusionary working-up the considerable weakness of judgment of the patient becomes very apparent. Even if it is expressly pointed out to him, he does not grasp the absurdity of his notion that the daughter of the English Consul at Quito should for over twenty years, here in Germany, try in such extraordinary ways to gain his love, and that she should dress herself up in man's clothes, and obtain help from every possible human being. He answers these objections by observing that one does not know what such an artful woman will not contrive. We are met by the same want of judgment in his over-self- appreciation. In spite of every failure, he does not see that he must lower his pretensions. He demands high pajTnent for his slow and purely mechanical occupation of copying or executing simple drawings. It can be seen, besides, that he is quite unable to execute works which require a certain originality, and when it comes to the point he admits at once that in copying he cannot keep the sense in his head. His conduct of life also, and the careless way in which he simply squandered his last farthing, are extremely significant of his incapability of grasping the true state of affairs, and of taking measures accordingly. We must add that he would not believe that his balance at the bank was exhausted, but was always demanding more money, lived on credit, holding out hopes to people of his prospective receipts, and finally he proposed to various fathers for the hands of their daughters in marriage, proceedings which gave the last stroke to his being taken to the district asylum, after having up to this point moved in his own circle without specially giving rise to suspicion. It is upon this last experience that I would lay special stress. Striking disturbances in the emotional department of the patient. Progressive Systematized Insanity 147 and especially in the department of the will, are wanting through- out. There is at the most a certain touchiness to be alleged, which shows when he is contradicted as to the delusions, and particularly as to his exaggerated ideas of self-esteem. But otherwise the patient is in neither a morbidly cheerful nor gloomy mood, nor is he emotionally dull or indifferent, but in a natural way takes interest in the events and persons of his surroundings, reads books and papers, occupies himself with drawings and sketches of his own accord, takes notice of his fellow-patients, follows the events of the day, chats with the doctors, makes new acquaintances, worries over disagreeables, and rejoices over appreciation. His outward bearing and behaviour are entirely unexceptionable and without remark, and are free from absurdity, automatic obedience, and negativism. Again, there are no sudden impulses, and the idea of inward constraint is absent, which develops in those patients who feel their thoughts and actions influenced in some strange way. Where he acts senselessly, the explanation rests unquestionably in his delu- sions. This distinctive disease, in which delusions of being wronged and of over-self-esteem develop quite slowly, without independent disturbances of emotional life or of the will becoming prominent, we shall call by the name of paranoia, or " mental derangement." In this disease there occurs regularly a mental working up of the delusion to form a delusionary view of the world — in fact, a " system." The disease leads to a " derangement " of the stand- point which the patient takes up towards the events of life. The malady always develops quite stealthily. First, suspicions begin to appear which gradually become certainties and steadfast convictions. The delusions become connected with real percep- tions and occurrences, which are construed only in morbid and prejudiced ways ; hallucinations, even if they appear at all, usually play only a subordinate part in the whole picture of disease, but we not infrequently meet with falsification of memory. As the patients maintain their outward bearing, the malady, as a rule, is only recognised after many years' standing ; hence the patients come seldom or late into the lunatic asylum, and mostly only for special reasons. They are generally in a condition without gross disturbances, and still able to engage in some profitable business. As the malady indicates a profound change in the mental personality, it is 10 — 2 148 Lectures on Clinical Psychiatry not accessible to cure.* It is much more usual after a number of years for a certain mental weakness gradually to develop out of it, as has become the case with our patient. The patients bear the asylum treatment badly, for they retain a lively sense of their independence, and take up the struggle for their freedom with the greatest vigour, if their energy does not finally flag with progressing mental weakness. Our patient also has sought to regain his freedom by numerous petitions, letters, and personal visits to the offices of newspaper editors. The master-tailor, aged forty-two, whom I wish to show you as an example of another form of the disease described here, has had a still more obstinate struggle. Seven years ago he became insolvent, and at that time fought out fierce lawsuits with the attorney of a principal creditor. Later on he removed to another town, but could not get on there, and fell into debt. Four years ago he had to leave a house that by purchase passed into other hands. The new owner, as vindication of his claim for rent, wished to have part of the furniture brought back through the bailiff, but was met by violent opposition, the patient simply locking up the bailiff as well as his companion, in order that meanwhile he might be able to lodge a complaint in court him- self. He was accused of false imprisonment, and punished. A short, humorously-treated notice of this affair appeared in a daily paper, in which the incident was incorrectly described as " distraint," and it was added that the accused had an intense hatred for the bailiff, who had been a frequent guest of his. Our patient was very angry about this statement, and sent in a correc- tion, which was only printed in part, and consequently did not satisfy him. He wrote an enraged letter to the editor, which was answered by a report in full of the further course of the proceedings, which went up to the Supreme Court. That the title " master-tailor " was printed in large type put the patient into the greatest excitement, and caused him to bring an action in the first place against the editor for private insult, then an action for compensation on account of damage to credit, and, lastly, an announcement of punishment on account of gross misdemeanour. All these complaints were rejected by the court on account of * The patient has been for the last nine years in a nursing asylum, without marked change in condition, where, by means of begging-letters, working out inventions, and going in for prize competitions, he endeavours to return to what he considers to be his proper position in life. Progressiv^e Systematized Insanity 149 insufficient grounds. The patient did not rest satisfied with this judgment, but gradually set in motion every means imaginable in order to attain his end. First, he went through the usual stages of appeal, up to the Provisional Court of Appeal and the Supreme Court of the Empire ; then came the complaint, the revision, the petition for appeal, the petition referred back to its original position, further petitions to the Ministry of Justice, to the Ministry of State, to the Grand Duke, and to the Emperor, besides to the Court of Administration and to the legal Govern- ment official. Petitions were also planned to the Diet and to the Federal Council, and interpellation of the Chancellor of the Empire in the Reichstag was planned, because he was answerable for the execution of the law in the Empire. Lastly, on the refusal of the judges and courts of justice, the patient tried the experi- ment of complaints to the heads of the courts, and held out in prospect the proposal of disciplinary proceedings against the Public Prosecutor before the Grand Duke, as well as a piteous appeal to the public for the support of legitimate interests. The innumerable petitions which the patient has drawn up in the course of the last few years, chiefly at night, according to his statement, are exceedingly long-winded, and always allege the same thing in a rather disconnected manner. In their form and mode of expression they incline to the legal document, beginning with " Concerning," going on throughout with " evidence," and concluding with " grounds." They abound in half or wholly misunderstood professional expressions and paragraphs of totally different laws. Often they are careless, and appear to have been written under excitement, contain numerous notes of exclamation and interrogation, even in the middle of a sentence ; one or more underlinings, some in red or blue pencil ', marginal notes and addenda, so that often every available space is made use of. Many of the petitions are written on the backs of judgments and refusals of other courts. In consequence of this incessant pestering of the authorities, the patient was at last pronounced to be mentally deranged, but against this opinion he adopted every possible legal means of redress, and at the injunction of the Highest Court of Appeal will now once more and conclusively be passed judgment upon by us. He has meanwhile carried on his business even under great difficulties, and, apart from his petitions, has not become strange or troublesome. 150 Lectures on Clinical Psychiatry If we now allow him to speak for himself, you will see that the patient is not only clear as to his position and gives a consecutive history of the events of the past, but is also able to express himself with great volubility and readiness for battle on the subject of his lawsuit. He does this evidently with a certain inward satisfaction. He is never at a loss for an answer to objec- tions, but justifies his action by the quoting of ever-new minutiae, principles of jurisprudence, and law paragraphs. In prolonged conversation a wearisome diffuseness certainly appears in his narrative, and the inclination to jump from one line of thought to another, but always to return in the end to the same expres- sions and amplifications. It can be seen from this that the patient looks upon the plaintiff's attorney, who co-operated in his bankruptcy proceedings, as the real source of his misfortunes, although he has not come into contact with him for six years. But when he wished to bring an action against the editor of the newspaper, the clerk of the court, referring to that earlier lawsuit, at first dissuaded him from it. By this it became clear to the patient that the attorney had prejudiced the clerk of the court against him, and furthermore sought to ruin him. All subsequent misfortune was only the result of this influence. The clerk did not draw up the accusation properly, so that it could not be carried through ; the Public Prosecutor got a wrong view of the matter from it, and the judges of the several law-courts, out of deference to their col- leagues, did not wish to reverse verdicts once agreed to. They were as a body " prejudiced." His affairs, therefore, in this particularly exceptional case, had been obliged to be referred to another court. Thus had the course of law been " systematically obstructed " to him. The whole business was a " secret con- spiracy " — " Freemasonry," for he assumes that his enemy had gone among the Freemasons. The whole body of Jewish financiers play a part in it, because the daily paper that wrote about him is, according to his opinion, supported by them. Also associated with the attorney are the " brigands of the press," the " Jewish sacrilege," the " subterfuges of the courts," the " violation of justice " by the attorneys appointed to him by the court, with whom he immediately fell out as soon as they did not follow his instructions, and, lastly, the incapability of his trustee, who throughout understood nothing of legal affairs. The patient's idea of being wronged goes back to one solitary Progressive Systematized Insanity 151 fixed source, but it has gradually involved and brought into connection with one another a whole series of persons who worked together, after a secret plan, for his ruin. This way of looking at things is everywhere supported on real occurrences, which are judged and interpreted by the patient alone in quite a one-sided manner. We see here plainly how that idea has developed to a kind of viewing of the world which affects in the most influential way the working-up of the later experiences of his life. In addition to this, the patient is quite impervious to reason. It is quite impossible to get him to admit that he may perhaps have been mistaken in his interpretation of the occurrences. On the contrary, he at once becomes mistrustful if one urges him on this point ; mere contradiction arouses in him the suspicion that we too are bent on supporting his opponents. All these features, the connection of the ideas of being wronged with a common starting-point, the extension of these in ever- widening circles, and, lastly, the imperviousness to reason, show us that we have here to deal with a delusion which takes deep root in the mental personality and is worked out into a system. There obviously exists along with it a certain weakness of under- standing, which shows itself in the monotony and aimlessness of his line of thought, as well as in his inaccessibility to the most obvious influences. His memory is generally correct, although, on closer examination, many of his assertions and wordy state- ments are found to be not quite reliable. In the emotional province we notice first an increased self- confidence. The patient displays a certain superiority, likes to show off his legal knowledge, and, in spite of every failure, expects a happy ending to his affair. He has no hesitation what- ever in again and again troubling the highest quarters with his petitions, for he looks upon his affair as one of quite special im- portance. As " a German and the father of a family," as " a man of business," he holds his " legal instinct " to be more authorita- tive than all the judgments of the courts. At the same time, he is exceedingly touchy, and answers each unfavourable verdict with the coarsest invectives, accuses the witnesses of perjury, the judges of corruptibility, speaks of " political-religious poisoning of wells," but says withal quite ingenuously that he always moves " within the bounds of propriety " himself. But the most striking point is the senseless action of the patient during the last few years, by which he has brought himself and 152 Lectures on Clinical Psychiatry his family more and more deeply into misfortune. He recognises this, but lays the whole blame on his opponents and the courts, who had forced him into it, and from whom he demands ever- increasing amounts of damages. It remains incomprehensible to him that he would now do best to acquiesce, and to spend all his energy in gaining a livelihood. On the contrary, he is already considering what way still remains open to him for making good his rights, should our verdict prove unfavourable to him also. The picture of life that is in broad outline disclosed to you here is that of a mentally -deranged, querulous person (or chronic grumbler). In the main points the picture agrees entirely with that of the former patient — that is to say, in the slow develop- ment of a delusionary view of the world from the morbid working out of the experiences of life, in the moderate but always gradu- ally progressing mental weakness, in the increased self-confidence, and, lastly, in the influencing of action by the delusion, with very trifling injury to memory and mental vivacity, without the appearance of independent disturbances of volition. Also, the lengthy course, the insignificance of the changes which the con- dition undergoes in the course of many years, and the funda- mental incurability, are common to both patients.* The disease usually begins in middle life, in connection with an imaginary or sometimes real injustice, forming a point of depar- ture for the whole medley of morbid ideas and actions developing one from another. Querulous people are not necessarily pug- nacious ; indeed, except on the subject of their delusion they are often good-natured and pleasant. But here, as in paranoia, the insignificance of the outward cause very much points to the fact that the real root of the malady lies in a morbid predisposition, and that we have to deal with a manifestation of degeneration. The insidious development of the disease, its fundamental in- curability, and the insignificance of visible disturbances would perhaps also be in favour of this view. * After six years the patient is still waging war, by every possible means, against the supposed legal wrong, and at the same time carries on his tailoring, though certainly ' very much in debt,' as he complains. LECTURE XVI PARANOIDAL FORMS OF DEMENTIA PR^ECOX Gentlemen, — ^The merchant, aged twenty-five, whom you see before you to-day, has made himself conspicuous by putting leaves and ferns into his buttonhole. He takes a seat with a certain amount of ceremony, and gives positive, concise, and generally relevant answers to our questions. We learn that he was admitted to the hospital a year ago, that he afterwards spent six weeks at home, and that he has now been here again for six months. The patient makes no explicit statements about the nature of the disturbances which appeared, but he admits, w'hen he is asked about it, that he did not speak for some time, he does not know why. But he remembers most of the details of what he has been through. Although he knows where he is, he mistakes the people about him, calls us by wrong names, and takes us for merchants. While he is more or less indifferent at first, taking very little interest in us and looking round with a conceited expression, he gradually becomes rather excited, grows rude, irritable, and threatening, and breaks out into an incoherent flood of words, in which there is a quite senseless play on syllables —"Macbeth— mach'insBett," "Irr ich michnicht— Klinik," " je suis — Jesus," and so on. At the same time, the patient intimates that he is the German Emperor, and that the Grand Duke is his father-in-law ; he has been promised the Grand Duke's daughter since 1871. He is studying astronomy here. He denies that he has hallucinations. He declines to obey orders, but after some persuasion he finally stretches out his hand stiffly to shake hands. The patient is divertible ; he often breaks off in his talk, and he intersperses it with curious snorting noises. His mood is changeable, but on the whole very much exalted. Often, more especially when he makes 153 154 Lectures on Clinical Psychiatry his jesting play on words, the patient bursts into a tittering laugh. His behaviour shows no marked excitement. His deportment is pompous and affected. The diagnosis will have to rest principally on the peculiar aberrations in the patient's actions — the mannerisms, the play on xvords, the signs of negativism, and also on his emotional in- difference, while he is yet quite collected. The patient does not consider himself ill, but stays here w-ithout making any resistance, does not worry at all, forms no plans for the future, and expresses no desires. We know this picture well already as a form in which dementia frcecox appears. What seems strange about the condi- tion is the absence of strong excitement on the one hand, and on the other the delusionary mistaking of people and the ideas of grandeur quite quietly expressed. But you will see at once, when we follow out the development of the case, that these deviations from the appearances discussed in an earlier lecture do not essen- tially affect the clinical interpretation of the patient's condition. The patient is said to belong to a healthy family. He was clever at school, was always serious and conscientious, and served as a one-year's conscript. So far back as three years ago he complained of being shaky and excited, and no longer able to work as he had once done. Then, after he had been particularly active and enterprising for some time, marked depression of spirits set in fifteen months ago. The patient became sleepless, and complained of pains in the back of his head. He felt stupid and unfit for work, took no pleasure in his business, played apathetically with his fingers, lay in bed all day, and thought that he had abused his principal's confidence and embezzled. In this way he came to the hospital. Here he showed a striking conjunction of emotional dulness with good comprehension and perfect lucidity. Very soon he sank into a stupor, became dumb, showed signs of automatic obedience alternating with negativism, and masturbated very much. He was afraid that the French were coming, and that the knife would be whetted and people made away with, heard threatening voices, felt electricity in bed, wished to die, and ate hardly anything. He was perfectly in- different when he was visited. It was only quite slowly that he became a little more active, got out of bed, and followed the doctor in his shirt, without speaking, or at the most murmured in a low tone to himself, or occasionally uttered irrelevant expressions, as to the meaning of which nothing could be learned from him. Paranoidal Forms of Dementia Praecox 155 In this condition he was taken home by his relations. There, too, he was almost dumb, and ate little, but jumped into a carriage one day, saying, " I drive a cab." He drove a little way, got out, and remained standing on the same spot for an hour and a quarter. During the next few days he suddenly became excited, clapped his hands, stamped with his feet, threw himself about, spoke quite incoherently in a loud voice about princesses, the Grand Duke, pardon, beheading, and the like, and laughed a great deal to himself. As he then became violent and broke windows, he was brought back to the hospital. Here he was very irritable and disobliging, gave senseless, irrelevant answers to questions, expressed disconnected ideas of grandeur, mistook people, and spoke and behaved affectedly. In speech and writing he plainly showed confusion of speech with playing on words. Thus he wrote in a letter, " 2x4 = 8, that is the day of the Lord come to pass ; good mine to bad man is bad ; bad wicked mine d'or to good man better as first recovery ; I B fiat in A — Saucier, you got — Minister — Mercier." When shown a knife, he answered, '' Knife, razor. Barber of Bagdad, Salem aleikum." On seeing a gold piece, " Louis d'or. Napoleon, Empress Eugenie, la France, Spain, thither will we go." He often spoke out of the window, and said he was talking to spirits or acting a play. His sleep was very much disturbed. The physical examination showed no ' abnormalities worth noticing, but great dermatography and mechanical excitability of the facials. His weight had increased considerably. The patient was originally supposed to be suffering from maniacal-depressive insanity. His previous history and the alternation of excited and depressed moods seemed greatly to favour this view. But in the further course of the case katatonic symptoms came out prominently during both the stuporose and the excited periods — negativism, mannerisms, automatic obedi- ence, and confusion of speech. The diagnosis we derived from the clinical condition is thus fully confirmed by the whole develop- ment of the disease until now. It is true that divertibility and quibbling, as we see them here, are generally considered to be symptoms of mania. I may, however, point out that in mani- acal cases it is only in the very worst states of excitement that the incoherence reaches as high a degree as it did here, where rationality was fully maintained and the excitement was com- paratively slight. Under these circumstances, we must certainly 156 Lectures on Clinical Psychiatry adhere to the diagnosis of katatonia. and may therefore suppose that considerable improvement in the patient's condition is still possible, but that even in the most favourable event a certain degree of dulness and want of freedom will probably remain in the spheres of emotion and action.* At first sight, the mechanic, aged forty-three, who takes his place before us now, seems to present much the same features as the last patient. He is slightly built, shows a certain formal politeness, and answers all our questions about his psrsonal circumstances quickly and correctly. He is clear about time, knows where he is, knows the doctor, does sums quite well, and possesses a fair amount of general knowledge. His mood is conceited, and a superior smile plays over his features. When asked what he is doing here, he suddenly comes out with a whole flood of the most fantastic ideas, which he utters with great fluency, paying absolutely no attention to objections. He has been brought here to have his mental condition observed, through the Black League. He is not ill, though potash, arsenic, prussic acid, sulphuric acid, and other poisons have been put into his food. He has been put under excommunication, inflicted by means of a mirror. In this mirror the spirit appears, through which men may communicate with spirits. There is such a mirror in every house where there is a member of the Black League ; even priests have it in the monstrance. The members of the League devour the born and unborn fruit of the womb, and make offerings of blood. " With these gifts, they inflict the excommunication, under the simultaneous stipulation if what they seek by their offerings is not granted, they stake their personal freedom. By offerings of dead life, it is understood that one is declared to be dead, but is not dead. Man need not die at all ; there are thousands who are only said to be dead, but are still alive and devour human flesh." " There are women, particularly Jesuits, who even sit on thrones, who are territorial princes, and others who are in high positions in the Government — Ministers, for instance. They make the sacrifice of uncleanness, and let themselves be defiled by beasts, even in church. There are even beasts which take the form of men. * When the patient had been eight months in the asylum, we were able to discharge him substantially improved. He was not very accessible, but fairly intelligent and free from delusions. Now. six years later, he is actively engaged in his business, but is shy, ' does not get on with people,' shows marked catalepsy, and expresses hypochondriacal delusions. Paranoidal Forms of Dementia Prascox 157 The worst of this evil dates from Chamisso ; that is seen in the very name, ' Shame-is-so '!" He goes on in this confused way. Whatever subject is men- tioned he immediately tacks on his monstrous delusions. Napoleon was used for uncleanness by Catherine I. in Russia. He got the testicles and penis of new-born children to eat, and so was turned into a hermaphrodite who could let himself be used by men, brought down misfortune on his head, and is now in- spector of a penitentiary. He has been given sweat-powder and cats' dung himself in his food, and has had his heart, liver, lungs, and testicles taken out. Parson Kneipp is enthroned as Germania on the Niederwald Monument ; Germania has a brother in the High Street at Freiburg. " That is the real ' Heit,' which is derived from heathendom [heidenthum] ; he calls that truth [wahrheit] ; he is not a real heathen at all." All these things are very fluently alleged by the patient as quiet self-evident matters of fact. When cross-questioned, he goes into details at once, explaining his statements with more and more monstrous assertions. But as soon as he sees that his word is doubted he becomes extremely irritated, and breaks out into a flood of abuse, saying that his questioner is also one of the hired assassins and a swindler and a hermaphrodite, and he can only be quieted with difficulty. Echolalia, echopraxis, and catalepsy exist in the patient. The knee-jerks are much exagger- ated, and the outspread fingers tremble, but no other physical disturbances can be made out. The clinical interpretation of this highly fantastic condition presents some difficulty at first. However, the senselessness and incoherence of the delusions, expressed with a complete absence of emotion, show that we have to deal with a state of mental weakness. The automatic obedience, the confusion and indecency of the patient's talk, and the quite senseless playing with assonances, remind us of what we have observed before in cases of dementia fracox. We also met with entirely similar disturbances in our last patient. If we look back to the development of the illness, we find that a sister of the patient was idiotic, and that he led a frivolous life himself, separated from his wife, entered into brief relations with other women, and served several terms of penal servitude for theft, forgery, and fraud. The first traces of disease appeared in the convict prison four years ago, in the form of hallucinations 158 Lectures on Clinical Psychiatry of hearing. The patient heard himself admired by his fellow- convicts for his blooming appearance, or threatened with arrest. The inspectois whispered, " Be quiet ; there he goes ; he has heard again. Good God ! what ears the fellow has !" People called out his first name and talked about him. Then hallucinations of taste appeared, and he mistook people, and only six months later more and more senseless ideas of grandeur and persecution gradually developed. These often changed and assumed new features, but gradually they took the forms still existing, while the earlier ideas disappeared. States of lively excitement, with a tendency to violence, were repeatedly observed. The patient has been in the hospital for three months. He generall^'keepsquitequiet, associates little with the other patients, does not occupy himself, lives for the day alone, is in a cheerful mood, says he is comfortable, greets the doctors in a rather formal way, and expresses no delusions of his own accord. But as soon as you get into conversation with him you find yourself under a shower of delusionary talk, consistent only in the main features. The patient gets increasingly excited, and more and more incoherent and irritated, but is friendly again next time he meets you, however abusive and threatening he may have been. He speaks in affected High German. The beginning of this course of disease, with the rather quickly- developed hallucinations, would agree quite well with our previous observations in cases of dementia praecox. We may add that the outbreak of the disease in prison is no unusual occur- rence. The great majority of " prison psychoses," or at least of those forms of them which run a lengthy course, belong to the province of dementia praecox. But we have never yet met with the luxuriant production of such extraordinary and constantly- changing delusions. For this reason the case before us bears a quite peculiar stamp, which formerly induced me to set this group of observations to a certain extent apart, under the name of " Dementia Paranoides." I think I may say from my experi- ence that such cases usually present almost exactly the same features for dozens of years, and neither recover nor become more mentally dull.* The delusions remain permanently active, * The patient has been in a nursing asylum for four years unchanged. She expresses confused and changeable delusions, and is at times very much excited ; but in the intervals she is quite collected and orderly in her behaviour. Paranoidal Forms of Dementia Prascox 159 and new and extraordinary forms are always succeeding one another. At the same time, there are hallucinations of hearing and often of sight also, and particularly a most remarkable change in the physical condition and the course of thought. In the sphere of the emotions, irritability may be observed, with complete indifference to the natural relations of life. Patients have a tendency to outbursts of loquacity, without feeling the need of occupation or purposeful striving for the improvement of their position, and without any thought for the future. This emotional enfeeblement, in conjunction with the symptoms previously described, leads us to assume that this condition may be closely allied to dementia praecox, in spite of many individual points of difference. Up to the present, I have not been able to discover any sharp division between the two clinical conditions ; indeed, there seem to be many transitional forms. If we bear in mind that in dementia praecox and maniacal-depressive insanity delusions in particular may either be wholly absent or may take on the most various forms of development, we will hardly have sufficient reason, considering the similarity of the disturbances in feeling and action, fundamentally to separate the forms described here from the various other forms of dementia praecox. The question is rather more difficult in another fairly large group of cases. The widow, aged thirty-five, whom I will now bring before you, may serve as an example of these. The patient gives full information about her life in answer to our questions, knows where she is, can tell the date and the year, and gives proof of satisfactory school knowledge. It is noteworthy that she does not look at her questioner, and speaks in a low and peculiar, sugary, affected tone. When you touch on her illness, she is reserved at first, and says that she is quite well, but she soon begins to express a number of remarkable ideas of persecu- tion. For many years she has heard voices, which insult her and cast suspicion on her chastity. They mention a number of names she knows, and tell her she will be stripped and abused. The voices are very distinct, and, in her opinion, they must be carried by a telescope or a machine from her home. Her thoughts are dictated to her ; she is obliged to think them, and hears them repeated after her. She is interrupted in her work, and has all kinds of uncomfortable sensations in her body, to . 1 i6o Lectures on Clinical Psychiatry j which something is " done." In particular, her " mother parts " are turned inside out, and people send a pain through her back, lay ice-water on her heart, squeeze her neck, injure her spine, and violate her. There are also hallucinations of sight — black figures and the altered appearance of people — but these are far less frequent. She cannot exactly say who carries on all the influencing, or for what object it is done. Sometimes it is the people from her home, and sometimes the doctors of an asylum where she was before who have taken something out of her body. The patient makes these extraordinary complaints without showing much emotion. She cries a little, but then describes her morbid experiences again with secret satisfaction and even with an erotic bias. She demands her discharge, but is easily ' consoled, and does not trouble at all about her position and her future. Her use of numerous strained and hardly intelligible phrases is very striking. She is ill-treated " flail-wise," "utterance-wise," " terror- wise "; she is "a picture of misery j in angel's form," and " a defrauded mamma and housewife of sense of order." They have " altered her form of emotion." She is " persecuted by a secret insect from the District Office." She gives her hand in a spread-out way, and is cataleptic and echopractic. There are no indications of physical disturbances of any clinical importance. The symptoms last mentioned will suggest the idea that the case belongs to the group constituted by the forms of dementia praecox. But the long and unvarying persistence of the same j delusions is very much opposed to what has been described hither- to. The patient's father was rather excitable, and a brother had convulsions as a child. Her former history shows that she has been ill for nearly ten years. The disease developed gradually. About a year after the death of her husband, by whom she has two children, she became apprehensive, slept badly, heard loud talking in her room at night, and thought that she was being robbed of her means and persecuted by people from Frankfort, where she had formerly lived. Four years ago she spent a year in an asylum. She thought she found the " Frankforters " there, noticed poison in the food, heard voices, and felt influences. After her discharge she brought accusations against the doctors of having mutilated her while she was there. She now thought them to be her persecutors, and openly abused the public authorities for failing to protect her, so she had to be admitted to this hospital Paranoidal Forms of Dementia Prascox i6i two months ago. Here she made the same complaints day after day, without showing much excitement, and wrote long-winded letters full of senseless and unvarying abuse about the persecution- from which she suffered, to her relations, the asylum doctors, and the authorities. She did not occupy herself in any way, held no intercourse with her fellow-patients, and avoided every attempt to influence her. Cases of this kind are very common. As a rule, the permanent delusions are thought to be of the greatest importance in their clinical interpretation, and for that reason they are generally classed under the head of Paranoia. To me, however, the patient's peadiar feeble-mindedness, which corresponds exactly to what is seen in dementia praecox, seems to be decisive of the diagnosis. The emotional dulness and loss of mental activity, the signs of automatic obedience and negativism, the mannerisms in the patient's behaviour, and the affected turns of speech, are symptoms with which we are well acquainted in that disease. There, too, we so often meet with the obstinate delusions of hearing, and even more with the delusion of influences on the body and on thought, that we can only look on the greater development of these disturbances here as a matter of degree, and not as an essential deviation from the ordinary features of dementia praecox. The condition before us differs from paranoia in some very essential respects. The delusions are quite without sense from first to last, and are not worked out in the mind. The patient feels no need at all to raise objections and refute them, or to get a clear idea of the personality, motives, and procedure of her persecutors. Important details such as their personality are altered by her quite unconsciously. There is a transformation of the delusions,but no extension of them,and they do not develop into a completed view of the world, but remain fantastic and only loosely coherent fancies. Here hallucinations of the most different kinds play a predominant part all the time, while in paranoia we saw that the delusions were almost exclusively connected with real experiences mistakenly worked out. I wish to lay special stress on the development of the ideas of being physically influenced — the so-called "delusion of physical persecution " — and more especially on the disturbances of volition manifested in the stiff and affected movements, the autom.atic obedience, the coining of new words, and the constraint of II 1 62 Lectures on Clinical Psychiatry thought, which, as far as I can see, are quite foreign to paranoia in our sense of the word. Lastly, as years go on, the purport of the delusions loses its influence on action fairly quickly, and the patients become dull and indifferent.* Very often the delusions are simply forgotten. The final condition may then be simple feeble-mindedness, which we see in other cases also as the outcome of dementia praecox. This result is never seen in real paranoia. It is from observations of this kind, more especially, that I am convinced that even those forms of feeble-mindedness which take their course with permanent delusions must not be called paranoia, but are more correctly to be brought under the head of dementia praecox. Where and when the limits of this over-extensive province are to be fixed the future alone can show. * The patient has been about five years in a nursing asylum. She is twaddling, affected, and negativistic. and still expresses her old ideas ot being influenced. ■ LECTURE XVII DIFFERENT FORMS OF DELUSIONS Gentlemen, — As we are continuing our discussion of the clinical and diagnostic meaning of delusions to-day, I will first show you a locksmith of forty-seven, who has been in the hospital for four months. The patient is collected, and has correct ideas of his surroundings, and very nearly so of time. He declares that five years ago, after influenza, he fell ill of pains in his loins and spasms round about his body. The nerves were so strained that he could not walk properly. Besides this, he suffered from constipation, and his water stopped once or twice. He is not insane, only " rather crazy-headed." He would like to be separated from his wife, as he cannot put up with her any longer. Since he has not been able to work he has become a burden to her, and then he heard how she said that he was a scamp, and she would rather have no husband at all. She has sold or pawned everything, and talked about him to the landlord, and said, " We could have had him taken away before this." Now he wants to marry again a pretty young girl ; when he can walk better again, he will earn enough to be able to carry that out. He has been persecuted for a long time to get rid of him. People spoke about him in the yard — " Yesterday evening would have been the time ; he could have been got rid of then." He has not been able to understand it all, but he has seen and noticed that he was influenced with an apparatus. That happened through his wife. It came from underneath, apparently with electricity, as if looking-glasses were moved about in front of his eyes. An impression has been made on his body with the apparatus, in his head, and on his hearing, so that there was a buzzing and whistling in his head. When he gets up, he feels the apparatus behind on his back, but he cannot see it. The patient's mood is indifferent, on the whole, 163 II — 2 164 Lectures on Clinical Psychiatry but often rather irritated. He thinks he has not the right nursing, that the food is bad, and that he could work again quite well. He is bitter against his wife, because she had him taken to the lunatic asylum ; but on persuasion he soon declares that he is ready to make it up with her again. He does sums fairly quickly and correctly, and his general knowledge corresponds to his position. The ideas of persecution expressed by the patient may perhaps remind us at first of those we know in dementia praecox. There, too, we very frequently meet with the delusion of being physically influenced. On the other hand, the expressions the patient thought he heard are like those of alcoholic insanity. The ideas of jealousy, as we will see better later on, would confirm the alcoholic origin of the illness. It is true that the patient alto- gether denies having drunk, and he is so poor in ideas and weak of judgment that there cannot well be any question of simple alcoholic derangement. But the supposition of dementia praecox, which is improbable, if only on account of the patient's age, is quite contradicted as soon as we examine his physical condition more closely. We discover disablement of the abducens on the left side, myosis, and inequality and reflex sluggishness of the pupils, while the accommodative reaction is still poorly main- tained. The left labio-nasal fold is effaced, the tongue is put out jerkily, the knee-jerks are lost, the gait is very uncertain and ataxic, and there is strong swaying when the patient stands with his eyes shut. Sensibility to pain is reduced, and the faculty of localization is bad. Speech is indistinct and slurring. These symptoms make it clear at once that we have to deal with general paralysis, accompanied in this case by delusions associated with hallucinations, and of quite a different kind from those we have already seen in this disease. You may look, if you like, for the cause of this peculiar variation in the greater participation of the sensory centres in the morbid processes ; at least, the view has been expressed that the paresthesis and sensa- tions of pain in disease of the spinal cord may be the foundation of the delusions of physical influencing. The idea of being dazzled may be due to morbid lightning sensations in the optic nerves, which are often affected in the forms of paralysis accompanied by symptoms of tabes. In our present case, unfortunately, incipient atrophy of the optic nerves could neither be proved nor disproved, as the incidental presence of opaque Different Forms of Delusions 165 nerve-fibres made an exact diagnosis impossible. The slight disturbance of the patient's memory and his good arithmetical powers are remarkable, as it is in this direction that the first pronounced morbid symptoms usually appear. This experience, like so many others, shows that we should never rely too much, in making a diagnosis, on the presence or absence of any one symptom, but must always keep the general picture before our eyes. In the previous history of the case we must notice that the patient is said to belong to a healthy family, and to have led a well-regulated life, free from dissipation. He admits that he had gonorrhoea twenty years ago, but denies all idea of luetic infection. There are two healthy children of his marriage. For five years the symptoms of tabes have gradually developed, particularly girdle sensation, ataxia, disturbances of the bladder and rectum, and impotence. Six months ago he began to grow excited, both sexually and otherwise, drank more than he had been accustomed to, and so became still more irritable, and thought that people persecuted him and wished to poison him, and that they wasted his money. Finally, he fled from his house, taking his papers with him. He applied for a divorce at once, and was then taken to the infirmary, where he slept very little, abused his wife, tore things, and was dirty. Thence he was brought to the hospital, and soon grew quiet, though he held fast to the old delusions, which he has just repeated before you now. Once a state of collapse was observed, with giddiness, pallor, and a very small pulse, which should probably be regarded as a slight paralytic attack. His weight increased at first, but is now gradually diminishing.* That the appearance of tabes should precede the development of the paralytic picture of disease by a considerable time, even by many years, is not at all unusual. This form of paralysis is generally called ascending or tabic paralysis. Whether the idea lying at the bottom of this name, that the disease, to a certain extent, ascends from the spinal cord to the brain, is correct or not seems rather doubtful. We are not even sure, as yet, that the tabes, which ends in paralytic disturbances, is essentially the same as the usual form of wasting of the spinal cord. As para- lysis is regularly connected with changes in the spinal cord, sometimes spreading more in the posterior and sometimes more * The patient died six years after the tabes began. 1 66 Lectures on Clinical Psychiatry in the lateral columns, paralytic disease of the posterior column might very well produce the clinical s5miptoms of tabes without the course of the disease being the same in both cases. In the clinical aspect it has struck me that in ascending paralysis the tabic symptoms are usually practically confined to the absence of sinew reflexes, myosis, reflex sluggishness of the pupils, and atrophy of the optic discs, while the rest of the disturbances, particularly the severe ataxia of the legs and the swaying, are either entirely wanting, or are far less developed than in ordinary tabes. But there is undoubtedly a very near kinship between tabes and general paralysis, especially in their relation to syphilis as a cause, and also in respect of the inefficacy of anti-luetic treatment. Our patient was formerly treated with mercurial ointment and iodide of potassium, without their arresting the disease or preventing the subsequent development of the signs of paralysis. We meet with delusions quite similar to those of the last patient in the farmer of sixty-five who came to us a year ago as an out- patient, but afterwards had to be brought into the hospital. He came here, for the first time, to look at an electrical apparatus, after having visited an optician for the same purpose. This per- fectly-collected and well-ordered patient can inform you of his motives himself. Indeed, he feels a necessity of expressing his ideas, and tells us that he has been persecuted for a year and a half by his neighbours, particularly by a shoemaker. His enemies have possession of an apparatus with which they can influence him in the most diverse ways. First he heard people talking about him, <5peaking evil of him, as if he had stolen, destroyed trees, and committed forgery. He recognised the voices plainly, and called the people to account, but they pretended not to know anything about it. It must be done with the telephone; His thoughts were " construed," too — " What I have thought, the others have said." Further, they threw black powder like chloroform at him by electricity ; it got into his mouth at night, and then it was like fire in his body. They threw the powder on the trees, too, so that the leaves withered ; he sent them to be examined, and the answer came back that it might be mildew. But the worst of all is the electric current they set at him with the machines ; it goes into his ear, his belly, and his sexual parts ; then it begins to twitch and burn, so that suddenly it almost throws him to the I Different Forms of Delusions 167 ground. Fiery rays shoot at him as he hes in bed, so that he thinks he is on fire. That is done with the treadle-machine the shoemaker has ; they also have horns i| feet long, like horns you blow on, and little things they can hide in their trouser- pockets. They set up steel posts, so that they can throw the current right into his bedroom, they are such experts. They have come into his house at night with the electric key and stunned him and hit him on the mouth. There was a stink, like burned leather or bones, left in the house. There was a stink of soap-boiling and phosphorus in the food. His head was often drawn together and his face pressed in, or he was hit ir. the side or on the belly, so that it hurt, and grew fatter, and was blown out, as it were, till the wind went away. The optician showed him a round glass thing with little tubes to it, but said the machine his enemies had must be bigger. A policeman who came round said that shoemakers had that. Then he ordered a price-list from a manufactory of electrical appliances, to see what the machines were like. He looked through the advertisements in the newspapers, as similar instruments were advertised there. In the current is the " sin-prognosis "; " that is just like outside at the telegraph ; everything that happens is announced there." The patient first called on the Burgomaster to help him against this persecution, and then applied in person and by letter to the district office, but they did not help him, and he soon discovered that the gentleman supported the shoemaker. He therefore tried to help himself, and placed the hot-water bottle on his head. He heard the ticking of the current in it, but could sleep, par- ticularly when he added a piece of iron. In the hospital, too, he asks for some pieces of tin, so as to be able to insulate himself on all sides. He would like still better to have a close-shut room, with thick walls that no rays could penetrate. He still keeps on writing addresses to the authorities, begging for protection, and intends to appeal even to the Ministry. The patient relates all this in a perfectly quiet tone. He is absolutely convinced of the correctness of his ideas, and is deter- mined not to be misled by objections. He hardly listens to them, and takes no trouble to refute them, but sometimes grows angry, and says that we are helping in it too, since we shut him up, and keep him back in an unjust way, and he therefore urgently demands his discharge. You can converse with him quite well about things remote from this, but he very soon returns to the i68 Lectures on Clinical Psychiatry subject of his persecution. His knowledge is full}' commen- surate with his position, and he also shows a certain degree of mental activity. He reads, occupies himself, talks to his fellow- patients, and plays cards, and his behaviour is in no way remark- able, apart from his measures of defence against the "rays." As he hears the shoemaker speak about him even here, and can get no sleep because of him, he tries to protect his head from the rays with little walls of bedding and any other articles he can obtain. A certain exalted self-esteem is to be noticed in his satisfaction that he is cunning enough to see through all his enemies' tricks, and does not allow himself to be hoaxed. As regards the previous history of the case, we must add that the patient comes of a healthy family, and was a temperate and industrious workman. He is married, and has five healthy children. The disease began eighteen months ago with ideas of persecution and hallucinations ; at times the patient also ex- pressed ideas of grandeur, saying that he would introduce a new religion, and improve agriculture all over the world. In the destruction of his person, the ruin of all mankind was aimed at, but he would make his persecutors harmless with an air-gun and a special kind of powder. The patient now professes to know nothing about these delusions. The interpretation of this picture of disease involves great difficulties. Such conditions are generally regarded simply as paranoia. It seems to me, however, that the sudden onset of the illness, the rapid development of a high degree of mental weakness and the predominance of vivid hallucinations of all the senses contradict this assumption. Besides, the delusions are not at all constant in detail, but often change. In this, and by their purport, they remind one very much of what is seen in dementia praecox. On the other hand, all the characteristic symptoms elsewhere known to us in that disease are absent here. Loss of mental activity, negativism, automatic obedience, stereotypism, and absurd and affected behaviour are wholly wanting. On this account, and also in consideration of the patient's advanced age, we cannot decide simply to regard this case as one of dementia praecox. Indeed, it will for the present be most in accordance with the facts to say that in advanced old age there is a picture of disease, " senile delusion of persecution," which has for its essential feature the appearance of fantastic ideas of persecution, with hallucinations and obvious mental Different Forms of Delusions 169 weakness. In practice such cases are far from rare. • The ideas of being wronged often take the form of delusions of jealousy. Commonly, the patient's condition remains unaltered for years, while the delusions continue, though their purport changes. In the further course of the illness senseless ideas of grandeur are usually associated with the ideas of being wronged. Some degree of reason is generally maintained to the end, yet the patients do not recover, but gradually become more feeble- minded and more flighty.* Lastly, a very peculiar form of the ideas of persecution is pre- sented by an officer, aged forty- two, whose illness is very inter- esting in many ways. The patient is perfectly collected, correct in his ideas of his position, and orderly. Neither in his mood nor in his intelligent and amiable behaviour does he show the least sign of derangement. He feels well and fit for work, has no complaint to make, and simply begs in a quiet and polite way to be allowed to return soon to his home and his duty. Only after a long conversation do we notice a certain want of clearness about his experiences in the last few years. It is true that he makes various statements about them, but these sound quite fantastic, and are often contradictor}'. The patient relates how he lived in the hotel at a watering- place, together with a member of the swell mob, who was intro- duced to him under an assumed name, broke into his room at night, and is now kept in a lunatic asylum, from which he will be discharged again as sane. This man has already been con- demned in a trial which you might have read about in the papers a little while ago. The patient himself thinks that his detention in the hospital must be connected with this affair. Ladies of high position are involved. On objections being made throwing doubt on this, he holds fast to his statements with complete conviction, and continually produces fresh details to establish the truth of his representations. From this it may be recognised that we have to deal with a peculiar disturbance, which is usually called falsification of memory. All kinds of pictures spring up before the patient, which in his eyes fully bear the stamp of genuine recollections, although there is absolutely no original corresponding to them in the past. These imaginary recollections evidently have produced * The patient has now been five and a half years in a nursing asylum unchanged. 170 Lectures on Clinical Psychiatry vivid impressions, for the patient describes all the details of such experiences with the words, " I still remember quite well," just as we would reproduce an event which has happened a few days ago with the words which were spoken then, the people who were present, and also quite unimportant accessories, which increase the certainty of the other statements. The more you talk to him about it, the more circumstantial does his story become, as new details keep on occurring to him. It is significant that he acknowledges himself that he had " never given another thought " to the whole affair, until it suddenly occurred to him. Thus he remembers falsely that a decree of divorce, already subscribed by several judges whom he names, was laid before him for his signa- ture. Particular people named were present as witnesses. At the same time, he was pledged to break off all communications by letter with his wife, and this he actually did for some time, on the grounds of this false recollection, and without any other cause. If the patient is led to talk about his past life, he relates, with the fullest conviction, a series of highly remarkable experi- ences— attacks which were made on him, little acts of heroism, and extraordinary occurrences, which have all arisen in the course of the falsification of memory. It is therefore quite impossible to get anything like a correct picture of his actual life from his descriptions. Besides, these accounts are anything but uniform ; they are subject to frequent changes, and new features keep on springing up, while others fade and disappear. Not unfrequently their connection with particular external associations can be recognised. Thus, the introduction of a new doctor very soon awakened the recollection in the patient that he had met him before somewhere, that his parents had lived years before in his own neighbourhood, and so on. It is quite comprehensible that actual recollections should be very indistinct and weak in this severe disturbance. In the case of this patient it is easy to satisfy one's self that after only a few hours the purport of a conversation is quite forgotten. Hence he often relates or writes the same thing many times, because he does not remember that he has done so before. Explanations remain in his mind only a very short time. When the doctor comes to see him, the patient forgets altogether that he has sent for him himself, to ask for his discharge. He forgets where he went for a walk or a drive yesterday, if he has washed himself, how much he has smoked, and if he has slept and eaten Different Forms of Delusions 171 well or badly, and on that account he sometimes repeats matters of daily routine several times. From special experiments made for the purpose, it appeared that after only half an hour he could not repeat more than a quarter of certain words of which he had been asked to take particular notice, while sane people of the same degree of education hardly forget a single word in that time. On the other hand, false recollections remain with him just as distinctly, and perhaps even more so, than true ones. Thus, the patient lay in bed in the morning for some little time, declaring that this had been prescribed by the doctor. All such falsifications of memory bear for him the stamp of the most complete certainty. He grows distrustful if you try to persuade him out of them, and suspects secret motiv^es in the background, the comprehension of which is soon laid open to him by new falsifications of memory. The delusions, however, govern the patient only temporarily, and are then superseded. They do not unite to form a view of the world. The patient always remains polite and amiable to the doctors, although he considers himself perfectly sane, and cannot understand why he is not discharged. The physical examination gives us the key to this very strange picture of disease. It is found that the muscles of the arms and legs are extremely flabby and feeble, yet the electric test gives no reaction of degeneration. On the other hand, the muscles show an unusually high mechanical excitability. All the nerves are very sensitive to pressure on the accessible points. The knee- reflexes are lost. On standing with the eyes shut, there is evident swaying, and also on quickly turning round. The outspread fingers tremble strongly. No other disturbances worth noticing can be pointed out, and in particular there are none in the pupils, or in speech or writing. This result of the examination shows that polyneuritis must have existed here. Now, we have learned from Korssakoff that psychical disturb- ances are observed in this disease which are principally dis- tinguished by the appearance of highly-developed falsification of memory. As a matter of fact, the previous history of the case shows that we have to deal with a polyneuritic mental disturbance here. The patient, who was originally mentally well endowed, though perhaps there was a slight heredity on his father's side, had an attack of inflammation of the lungs ten years ago, and made a very slow recovery. During his convalescence he became accustomed to considerable indulgence 172 Lectures on Clinical Psychiatry in alcohol, and afterwards he suffered from polyneuritis. Ap- parently there was also syphilis, of which the indications were removed by treatment with iodide of potassium. The neuritic disturbances fluctuated at first, but gradually became more severe with the patient's increasingly intemperate habits, and often interfered with his work. Very soon after the illness began a slight weakness of judgment became obvious, inasmuch as he did not realize the significance of his condition. In the last few years feebleness of will and forgetfulness also appeared. He was incapable of abstaining from alcohol, and apparently did not know how much he drank. Three years ago a delirious condition was transitorily developed. After abstention from alcohol for any length of time, all the s>Tnptoms quickly improved till only a certain residue remained, but they returned with still greater force when the patient was left more to himself and drank again. For several years the falsification of memory became more and more evident, at first in the combination of truth and falsehood, and then in pure invention. The development of delusions, as the result of the falsification of memory, finally led to the patient's being brought to our hospital. You will see that the way in which the delusions arose and their clinical meaning are both quite different from those we have observed in any of the cases considered hitherto. This, too, may warn you against overestimating the diagnostic value of this symptom. But it must be recognised that the particular clinical form of the delusions, though not their existence in themselves, may perhaps make it possible to decide as to the nature of the case. If our patient's perfectly orderly behaviour and faultless bearing remind us of paranoia, this suggestion is soon disproved by the instability and vagueness of the delusions, which have very little influence on the patient's relations to his surroundings, although they are advanced with the greatest confidence at the moment. In this respect they are more like those of general paralysis or dementia praecox, but the diagnostic physical dis- turbances of the one and the peculiarities of action and behaviour of the other are absent. We see neither the disablement of general paralysis nor its far-reaching mental and emotional impoverishment and advancing course, while the disturbance of the faculty of retaining impressions is far greater here than it is in dementia praecox. These differences are all the more im- portant because falsification of memory occurs in both those Different Forms of Delusions 173 diseases, and, though not so well marked as what we see in the present case, may be very like it in other respects. Polyneuritic mental disturbance is not exactly a common disease, although perhaps it may sometimes be overlooked. It appears to be the result of a toxin on the cerebral cortex. It is often preceded by tuberculosis, and almost always by alcoholism. Some patients recover after several months of illness, but in others, as in the present case, an incurable state of weakness is developed, betraying its peculiar nature in the falsification of memory and the traces of neuritis.* The treatment consists of very careful nursing and permanent deprivation of alcohol. In the present case it has come too late. * The patient has been five years in a private asylum unchanged. LECTURE XVIII CHRONIC ALCOHOLISM Gentlemen, — It is only in a comparatively very small number of cases, in the province of clinical alienism, that we are able to form anything like a reliable idea of the causes of the morbid phenomena, and still more seldom can we give an account of the way in which those causes work. For obvious reasons, we most nearly approach the latter goal of clinical inquiry in cases of poisoning, particularly in those which daily experience fre- quently brings before us. We know that acute alcoholic poisoning produces changes in the cortex of the brain which can easily be pointed out, and that the expression of these changes in intoxica- tion consists of difficulty in comprehension, shallowness of the train of thought, and increased psychomotor excitability, with loss of strength and disturbance of the finer control of the move- ments. It is also known that the effect of large doses of alcohol may continue for from twenty-four to forty-eight hours, and that, by the regular repetition of the doses before the effect of the previous dose has passed away, a permanent reduction of the mental capacity for work in various departments is produced in a few days, and disappears only very slowly, even when the administration of the poison has ceased. These facts, which have been discovered by actual experiment, are calculated to give us a certam comprehension of the onset of the mental disturbance called chronic alcoholism. If you examine the merchant, aged thirty-three, who entered our hospital of his own accord a few days ago, you will probably hardly notice any symptom of disease in him. He is perfectly collected and clear, and gives well-ordered information about his whole circumstances. His features are rather flabby and bloated. The knee and skin reflexes are very active, and when he spreads 174 Chronic Alcoholism 175 out his fingers there is a fine tremor. The gums and mouth are very red, and the tongue is a Httle furred. The patient states that he entered the asylum because he had drunk hard latterly. He did well at school, but when he was about sixteen he was induced by his father's drinking habits to drink beer pretty regularly, and got a taste for it, which, with many fluctuations, has gradually become more and more strongly developed. His marriage, when he was twenty-six, brought about an improvement for a little while, but afterwards things got worse and worse, until finally he spent nearly the whole day in a certain state of intoxication. In this condition, he was irritable, scolded on trivial occasions with the lowest expressions, became careless and negligent in his work, and ate only very little at home. On his wife's persuasion, the patient, who is good- natured and easily influenced at home, let himself be admitted here, and remained nearly four months in the hospital, where all the disturbances disappeared very quickly. He was urgently advised by us to remain a complete abstainer, and he followed this advice for eighteen months. His capacity for work had been greatly increased, so that he earned considerably more than before. His wife in particular was delighted with the change in her husband's nature, as the patient had become cheerful, amiable, and very domestic. Four months ago he began to drink again, from curiosity, as he said, and to see if he could stand it. His comrades' example had awakened the wish to be able to drink just a glass now and then, so as not to " hang back " behind them. At first he was moderate, but very soon he was unable to restrain himself. " After the first glass one gets angry and excited, and then one goes on drinking without knowing how !" For the last few weeks he drank very hard, mostly champagne. Of course, he neglected his work, and when he saw that he no longer had strength to control himself, he begged to be admitted to the hospital again. In the course of this narrative, the peculiar, humorous mood in which the patient relates his experiences strikes us once more. Thus, he says that he has drunk ever since he was born, for that is the first thing a man learns to do. He also tries to excuse his drinking a little, although he has clearly recognised his indefen- sible position. Both these features are characteristic of drunkards. They depend on the effect of alcohol on the emotions, which leads us to take serious things lightly, not to trouble about ij6 Lectures on Clinical Psychiatry anything, and to throw our sense of responsibility overboard. You will never find a drunkard who lays the blame for his drinking on himself, as long as he is under the infiuence of the poison. It is always the peculiar circumstances — his occupation, his com- rades, and especially his wife — that are responsible for his drink- ing. The sense of his own want of independence and steadiness, revealed in these statements, is, in fact, only too well grounded on the weakness of will developed in every drunkard. The fact that our patient's capacity for work was seriously impaired is partly explained by the immediate effect of the individual amounts of alcohol which he took at very short intervals. But it has been shown by experiments with the patient that even now, a fortnight after having entirely given up alcohol, there is still a very considerable disturbance of comprehension, and also that in simple copying he makes an extraordinary number of mistakes, and is very forgetful. These are disturbances which are perfectly familiar to us in the picture of chronic alcoholism. The life-history which I have brought before you here shows quite the usual course of things in numberless cases of chronic alcoholism — temptation in youth through our drinking customs, the gradual growth of the taste for drink in a good-natured and rather weak-willed man, the degradation of his conduct and family circumstances, the good resolutions which are always abandoned in temptation, and the rapid improvement on total abstinence. We carmot doubt, however, that the weakness of will produced by the poison continues for a very long time in a drunkard ; at any rate, the danger of occasional relapses is extraordinarily great. Indulgence in alcohol itself, in particular, even in very small quantities, immediately weakens the power of resisting temptation. We all know that nobody sits down to get drunk, but that, under the influence of the first few glasses, self-control is more and more completely lost, just as our patient describes. We must therefore try to induce all our alcoholic patients to abslain completely, if we would obtain permanent results. Even then there will be many disappointments. Still, it is possible in half or even two-thirds of the cases which are taken in time to obtain the permanent recovery of drunkards. In all the more severe cases treatment in an asylum is indispensable, as in ordinary life the enfeebled will of a drunkard is exposed to many temptations which he cannot resist by his own strength. Un- Chronic Alcoholism ^11 fortunately, it is only now that a few asylums are being provided for drunkards, so that they can hardly be dealt with except in lunatic asylums — a circumstance which naturally makes the prompt treatment on which everything depends very difficult. Too often drunkards only come under correct treatment when they have become a public danger, and so exhibit the most severe forms of alcoholism. In our present case the prospect is not unfavourable, insomuch as the patient has a clear sense of his own need of help, and came to our hospital both times of his own accord. He may also have been fully convinced, by his relapse, that only strict and total abstinence can save him in the long- run. We may therefore hope that it will be possible, not only to restore him to health for the present, but also to keep him well for the future.* There is a much less favourable state of things in the case of a wire-drawer, aged thirty-four, who was brought here a few days ago from the infirmary. He was there because he had committed a disturbance of domestic peace by making a forcible entrance into the house of his mother-in-law and breaking a glass door. The patient is perfectly quiet and collected, has correct ideas of time and place, and gives connected information about his circumstances. His school knowledge is very moderate. While he is quite at home in subjects which concern him inti- mately, he can only give very inadequate answers to rather more general questions in the departments of knowledge of the country, history, politics, and religion. With regard to the recent occur- rence, he says that he has suspected for some time that his wife was unfaithful to him. He could not say it for certain, as he is away from home all day, but three months ago, after sleeping with her, he noticed a burning which he thought suspicious. It is true that a doctor whom he consulted told him that his wife's pregnancy, of four months' standing, might be the cause of this. A fortnight ago, when he came home, he found the sofa in disorder, and concluded that his wife had committed herself with another man during his absence. At that he made a violent scene with her. When he came back in the evening, he found that his wife was not at home, but had gone to her mother's house. As she would not return with him, he rang the bell very loudly, and pushed in the panes of a glass door " by accident." This story will at once arouse the suspicion of a delusion of * The patient has been well and a total abstainer for nine years. 12 178 Lectures on Clinical Psychiatry jealousy. Of course, we ought always to be very caieful in making such an assumption. But the theory of a morbid origin for the idea is strongly supported by the indefinite nature of the statements and the extremely insufficient grounds of suspicion. What the patient says he observed evidently proves nothing at all, and therefore his jealousy has not arisen on the ground of experience. On the contrary, the facts, which show nothing in themselves, owe their special interpretation to the jealousy which has arisen on other and morbid grounds. The delusion of unfaithfulness in marriage is not in itself diagnostic of a particular disease, as it may develop in v^ery different mental disturbances. But it is most common in advanced age and in alcoholism and cocainism. As the last is altogether improbable on account of its rarity and expense, the ideas of jealousy lead us at once to the assumption of alcoholism. The patient, however, when questioned on this point, says that he has hardly ever been drunk ; he only drinks his " filj." He has generally drunk three or four bottles of beer in the day, with a glass or two of beer besides, but never spirits. He worked so hard that he could not eat anything at home. We would be very much deceived if we were to drop the assump- tion of chronic alcoholism merely on account of these statements.- The last remark about not eating is very suspicious in itself, as the abuse of alcohol is a very frequent cause of such disturbances. And the amounts of alcohol given by the patient are considerable enough if we remember that, in spite of the universal admiration of the power of heavy drinking, drunkards always have a ten- dency to estimate the amount they habitually take as low as possible. If we look more closely at the patient, we will find that he is prematurely aged and very gray. His outspread fingers plainly show a fine tremor, and when he puts out his tongue its tremor is also distinct. The knee-jerks are exaggerated, but no other conspicuous physical disturbances can be seen. The tremors, as they exactly resemble those of chronic alcoholism, give fresh support to our suspicion. \i we turn to our patient's previous history, we learn that he has- always drunk a great deal, and spent most of his wages on him- self. For the last six months he has expressed ideas of jealousy against his wife, and threatened and beat her, so that she was not fit to be seen. He used the lowest expressions, even before his children. WTien he was taken to the infirmary on account of Chronic Alcoholism 170 the last scene, he was fast asleep, and evidently under the influ- ence of alcohol. When we bring these statements to the patient's notice, he says that all that is very much exaggerated. There have certainly been little quarrels now and then, as there are in every household, but he has never threatened or ill-treated his wife. He only beat her a little once, when she did not give him some important news in time. As to her unfaithfulness, he may very well have been mistaken, and he will never say another word about it. He can give up drinking quite well, and he sees now that it does him no good. You see that our suspicion has been fully confirmed by the further examination of the case. We find all the characteristic features of habitual drunkenness in our patient — the loss of wider interests, the selfishness which leads him to an exaggerated personal expenditure, the brutalization of his conduct, seen in his ill-treatment of his wife and his wild outbursts before his own children, and, lastly, the morbid jealousy which develops very often in drunkards, perhaps on account of the inevitable moral estrangement ot husband and wife. This last symptom is par- ticularly important, as the jealousy often leads to dangerous violence against the wife. Generally, too, it only appears after severe alcoholic deterioration of character. That the patient flatly denies his drunkenness ought not to surprise you. This, too, is a common phenomenon in drunkards, just as people who are drunk will hardly ever admit that they are intoxicated. Neither must you be deceived by the patient's fine promises. You may hear such promises from almost any drvmkard, who has abstained for a little while. But even if thej^ are really meant, and are not simply a means of obtaining his discharge as soon as possible, a drunkard's weak will is, as a rule, unable to resist the least temptation. In all cases of any severity it is only after the lapse of a year that patients stand really firm on this point. Unfortunately, we have hardly any means of keeping patients wanting in insight against their will, until their recovery from the disturbances produced by alcohol can gradually be completed.* As the conspicuous symptoms of the disease disappear very quickly, we are obliged to leave such * On his demand, the patient had to be discharged after only a week. His condition has little by little become so much worse that his wife was obliged to separate from him four years ago. He went on drinking, and his lungs are now said to be affected. 12 — 2 i8o Lectures on Clinical Psychiatry a patient to his fate far too soon, although we have it clearly before our eyes, not only that he will certainly relapse, but also that he constitutes a serious danger to those around him, or, as in the present case, to his wife. It is obvious that much good may be done here by the total abstinence societies, which take these patients under their protection at once, and afford them so much support that many win their way to permanent abstinence by this means who could never have done so by their own unaided strength. A very similar picture to the last — at any rate, at first sight — is presented by a farmer, aged forty-four, who has now been admitted to the hospital fifteen times. He is said to come of a healthy family, and was mentally gifted, but is considered un- steady. After serving as a soldier, he married at the age of twenty-four, and has two healthy children. He has been given to drink since he was twenty years old, and his circumstances have been reduced by his extravagance when drinking. He drinks, however, only from time to time, for a few days or weeks, but then takes anything he can get, in quite unreasonable quan- tities, without getting actually drunk. When the impulse to drink comes over him, no one can stop him. He forces his wife to give him money by serious threats, and runs at full speed to the nearest public-house, sometimes in the middle of the night. His whole bearing is then excited and irritable ; his eyes shine, he talks a great deal and very loudly, and does not stay long anywhere, but runs from one public-house to another. He goes about by railway or in a carriage to places in the neighbourhood, treats other people, and spends his money recklessly. The sums expended on these occasions are often very considerable. Once in two days he got through 130 marks, which he had withdrawn from the savings-bank a little while before. These outbursts cease after a time, and then the patient does not usually know exactly what he has been doing, and more especially where his money has gone. He is also in great trouble about what has happened, and is quite temperate, often not drinking a drop of spirituous liquor for a long time. His weight, which has fallen greatly during the drinking, is now recovered quickly. For the first few years these attacks of drinking came on about every three months, but afterwards they grew more and more frequent, until at last they returned after only a week. During the last seven years since we have known him there has Chronic Alcoholism i8i been some improvement, and the patient has several times had periods of freedom extending over many months. But the whole course of the illness has been very irregular. If we turn now to the tall and strongly-built patient himself, there is hardly any striking physical disturbance to be seen. He is collected, and is perfectly clear about his position, feels ill and depressed, and complains of pressure in his head. Unlike the last patient, he wishes to be cured at once. " I cannot help drinking, and do not want to drink," he says. In his morbid states, as he describes them, he grows ill-humoured, stares peevishly in front of him, and feels an inward restlessness, which drives him forcibly to drink. " To drink all day long, only drink, always at it ; one has to drink, whether one likes it or not — it is a kind of impulse from within." It goes again suddenl\% " as if it fell from me." " When it comes I have to go to the public- house, and when it is over I have a loathing for it. You might give me money ; I have no craving for it at all then." From these expressions, which agree very well with the statements of the patient's wife, it is clear that we have not to do with an ordinary drunkard. We have rather to deal with that form of alcoholism which is usually called dipsomania, and is characterized by the periodical instinctive setting-in of the tendency to drink, while in the intervals little or nothing is usually taken. The starting-point of every attack of this kind, as can easily be proved, is a state of depression, a feeling of discomfort and rest- lessness within, which patients try to escape by drinking. Then, under the influence of the alcohol, they pass into a state of excite- ment, which constantly drives them to fresh drinking, until the attack suddenly comes to an end. There are two facts of the greatest importance for the clinical understanding of these so-called " quarterly topers." In the first place, we very frequently find these conditions in patients who undoubtedly suffer from epilepsy, and, secondly, it appears that in dipsomaniacs, when, as in our present case, there is no possibility of their being supplied with alcohol, the attacks pass off in the form of simple and very transitory depression, exactly resembling that of epileptics. I could also point out to you, from our observations of the last few years, every conceivable form of transition from dipsomania to ordinary epilepsy. At one extremity of the line are patients in whom periodical states of depression, of dipsomaniacal colour- 1 82 Lectures on Clinical Psychiatry ing, appear in combination with severe attacks of convulsions. Next come cases in which epilepsy is only noticeable, apart from attacks of dipsomania, in isolated fainting fits or states of semi- consciousness. Finally, we have to record observations in which, as with our present patient, dipsomania is the only sign of disease. All these facts make it impossible, as I think, for clinical reflection to see anything else in dipsomania than one of the manifold varieties of epilepsy. Even though drinking seems at first to be the most prominent feature of the cases, yet it is only an accompanying symptom, and is as far as possible from being the real cause of the attack. But it certainly very greatly aggravates the con- dition, as we have already seen in the states of semi-consciousness and the morbid states of intoxication in other forms of epilepsy. From this it follows that, in spite of many points of resem- blance, dipsomania must essentially be distinguished from ordinary drunkeimess. In practice, the alcoholic deterioration of the whole man is usually less in dipsomania, because of the short duration of the single attacks, although they are often very severe. For this reason, dipsomania presents, on the whole, a more favourable prospect of overcoming the alcoholism than ordinary drunkenness. Of course, a long and careful education of the patient in total abstinence is necessary, a point we have, unfortunately, not been able to reach in the present case. If the patients possess enough strength of will and understanding of their malady to abstain from all indulgence in alcohol throughout their whole life, not only do the attacks generally pass off in the form of slight and comparatively harmless depression, but they also gradually become decidedly less frequent. During the depression rest in bed is most to be recommended, with a large dose of bromides under some circumstances. Our patient has repeatedly helped himself over an incipient attack by taking from I to 2 grammes of sulphonal or trional a day, and then sleeping until all tendency to drink had disappeared after a day or two.* * The patient comes into the asylum several times every year for a short time, either before, during, or after an attack. He has now been admitted thirty- two times in eleven years. LECTURE XIX MORPHINISM AND COCAINISM Gentlemen, — It is certain that every doctor will consider it the highest principle of his professional duty not to injure his patients. Yet I must introduce you to-day to no small group of psychical disturbances originated almost exclusively by the indiscretion of medical men. First, you see before you a farmer, aged forty-four, who received a gunshot wound in his left hip twenty-one years ago, which grazed the pelvis and apparently also injured the sciatic nerve. As the result of this injury, he often had tearing pains in the thigh, which made walking very diihcult and necessitated a series of cures at health resorts. Five years later the ball, which had remained in his body, was extracted, but the pains continued as before. Morphine was administered to relieve the pains from the first, and its employment was afterwards left to the patient himself. Of course, he did not observe the rules of asepsis in making the injections, and numerous abscesses formed. He therefore decided, about sixteen years ago, to take the solution of morphine inter- nally. As is ahvays the case, the remedy soon became an in- dispensable necessity of life. Whenever he left it off, tiredness, depression, disgust, and a feeling of oppression set in, which always drove him back to the use of the poison. Soon the doses he took at first were not enough to obviate the sufferings which arose from the use of the drug, and the patient was obliged to take it in constantly increasing amounts. He often tried to reduce the dose, but always made shipwreck on the very severe suffering already mentioned, which prevented his reducing the doses beyond a certain point. It seems that, at times, he came down to about o-o6 gramme a day, but latterly he again took three 183 1 84 Lectures on Clinical Psychiatry times as much. However, his statements on these points, as is always the case with this class of patients, are not very reliable. For the moment, you see nothing very noticeable about the patient, who tells us his history in a rational and connected way. He finds his dependence on the drug very irksome, and has a lively wish to be freed from it, especially as it really has no effect at all on his pains, but only obviates the suffering arising from his leaving off the remedy itself. The patient feels more infirm than he did, sleeps badly, and has little appetite. His nutrition has also fallen off, but he is strongly built. The pupils are small, a sign of morphine poisoning, and the hands tremble a little. Both arms and thighs and breast are quite covered with whitish, shining, sinewy scars, arising from the injections and abscesses. The flexibility of both elbow-joints is very much limited by cicatricial contraction. These scars are an infallible sign of the abuse of morphine or similar remedies, and are absent only in a few cases where the poison is taken internalh- from the first. There is a small, non-adherent scar of the old gunshot wound remaining on the left edge of the pelvis. In the left leg no disturbances of movement in any direction can be found, but the patient complains of an unpleasant creeping in the sole of the foot and toes, and piercing pains in the left thigh, as well as of fleeting sensations in the rest of his body, which can only be referred to the craving for morphine. The patient's memory and understanding show nothing abnormal. In the emotional sphere there is perhaps a certain tendency to self-pity. Little as the sjTnptoms of disease at first strike the eye in prolonged use of morphine, the whole malady has the most serious results for those whom it attacks. So far, all we know from experiments about the psychical effect of morphine is that apparently it makes the course of thought easier, but renders the carrying-out of the impulses of volition more difficult, and so disables the will. This last effect also becomes clinically prominent in the picture of chronic morphinism. The patients become flabby, and lose their power of action, their endurance, and their pleasure in work, and are thus most severely injured in their whole activity in life. To this must be added the con- tinual alternation between the mentally exciting effect of the individual doses of morphine and the phenomena of deprivation, which set in after a few hours, and consist of painful inward restlessness and feelings of anxiety, and also of yawning, sneezing, Morphinism and Cocainism 185 diarrhoea, sweating, palpitation of the heart, and many other tormenting sensations, which drive the sufferer headlong to fresh use of the poison. Finally, there regularly appears an exaggerated sensibility to all kinds of pain and mental shock, inducing the sufferers to have recourse to injections for compara- tively very trivial causes. In this way the morphine unfailingly becomes the central point of the patient's whole interest in life, to which all other considerations are subordinated, and an absolutely slavish dependence on the remedy develops, which is proof of an infirmity of the will. With this are associated sleep- lessness, defective nutrition, diminution of the physical power of resistance, and exhaustion of sexual ability. Unfortunately, it is extremely difficult to overcome this fatal malady. Of course, we must first withdraw the morphine, and this may almost always be done without serious difficult}' in the course of two or three weeks. It is dangerous to cut off the supply of morphine suddenly, on account of the collapse which results. As patients generally say that their dose was larger than it really was, and also regularly take more than is necessary to relieve their sufferings, the dose may be reduced pretty quickly at the beginning of the cure. We gave our patient 0"i6 gramme on the first day, and on the second day o-i2, and now, after a fortnight, we have come down to 0-04 gramme. The patient's discomfort has been very slight — a little restlessness and bad sleep, and in the last few days a little yawning and sneezing, with slight diarrhoea. The appetite has remained pretty good. In three or four days we intend to leave off the drug, keeping the last dose for the evening, to let the unpleasant phenomena pass off as far as possible in the daytime. Meanwhile, the patient has to keep strictly to his bed, is nourished as well as possible, especially with milk, and takes a prolonged warm bath daily. No impor- tant disturbances need certainly be expected now. With the withdrawal of the drug, however, only a small part of the work has been done. It is much more important to pre- vent the extremely frequent relapses. In a still higher degree than in alcoholism a lowering of the power of resistance remains after the abuse of morphine, which leads the patient to have recourse to the drug at once, when suffering from overexertion, disagreeable conditions, or pain. This disturbance disappears only very slowly, generally not till after a full year, while mor- phinists usually consider themselves cured as soon as they have 1 86 Lectures on Clinical Psychiatry gone without morphine for a few days. Until this fatal self- deception is entirely done away with, and morphinists are placed under careful oversight and treatment, for at least as long a time as is now recognised to be indispensable for alcoholics, the very gloomy prognosis of morphinism will hardly improve. It shows an inexcusable want of conscience that every day in newspapers and pamphlets doctors should promise morphinists " a certain cure in thirty days, without restraint or discomfort." The with- drawal of the morphine in this time, without great suffering, is certainly not a work of any special skill. But the man who calls morphinists cured then deceives either himself or his patients. The unhappy victims of such advertisements wander from one institution to another after they have entirely lost their faith in themselves and in their doctors. It is impossible to say with certainty what form our patient's future will take. In his circumstances he cannot, and will not, devote more than seven or eight weeks to his cure, although we have made the great danger of a relapse clear to him. Yet it is not quite impossible that he may remain free, as he has taken only comparatively small doses, and is a man of insight, whose strength of will does not seem to have been greatly impaired, and as the pains, which were the cause of his using the drug, are comparatively trifling.* Things are much more serious for the tanner's wife, aged forty- four, who may serve as an example of the more severe forms of morphinism. The patient is collected and clear about her position, but is in a very irritable mood. When her abuse of mor- phine is spoken of, she breaks out into violent scolding because she is deprived of the drug. She declares obstinately that she will begin to inject again at onf^e, and threatens to strangle herself at the first opportunity, saying that it is very easily done. The patient is small and ill-nourished. Her teeth are bad ; her tongue is slighth^ coated and trembles. You also see a tremor in her outspread fingers. There is a coloboma in the left eye, arising from iridectomy. There are numerous shining scars on both arms and both hips. Our patient has been here once already, four years ago. Her father drank, and her maternal grandmother was paralyzed. She married thirteen years ago, and has two healthy children. * The patient is said to have remained free from morphinism until his death ten years after he was discharged. Morphinism and Cocainism 187 Her illness began seventeen years ago. At that time she had to undergo an operation for acute glaucoma, and the doctor gave her morphine ; then the nursing sister, who was herself a mor- phinist, went on giving it to her, so that she got accustomed to it. Later on she got the doctor to prescribe the drug at first, but afterwards got it from a chemist's shop without a prescrip- tion. She got the money for it by selling leather secretly, or opening her husband's safe with false keys. At last her husband took the administration of the drug into his own hands, but, as he never gave her enough, she used to outwit him in every possible way, taking morphine from the bottle secretly, putting water in, and then upsetting it. In the course of the last ten years she has used several thousand marks' worth of morphine, so that the domestic circumstances of the family have suffered greatly. Her condition kept getting worse and worse, and every- thing centred with her on the morphine. The patient became unsettled, unstable, and apprehensive, and could not work with- out injections of morphia. She ate and slept very badly, fell off in her nutrition, and looked pale and haggard. The menses dis- appeared almost entirely. In the last few years the patient has begun to drink. All attempts to wean her from the morphine having failed, it was finally resolved to bring her to the hospital. She was said to have used from i to 2 grammes of morphine a day at that time. However, the withdrawal of the drug, which was carried out in five days, caused no particular suffering, so the dose was doubtless estimated far too high. There were only slight restlessness, a feeling of oppression, and a little diarrhoea. But during the withdrawal, and for a few days after, the patient was very much irritated and wanting in insight, and declared that she would get herself more morphine at once, although she had begun the cure at her own wish. It was only later on, with an increase in the patient's weight, which had fallen at first, that she grew more reasonable and confident, and said that she would never relapse again. With this idea, she would not stay here, in spite of all our warnings, but left the hospital, with her husband's consent, after only two months. The relapse which, under the circumstances, we confidently expected followed, as the patient asserts, within the first few days, but her husband did not notice it till a year after. Very soon the old condition returned. If the patient had no morphine. 1 88 Lectures on Clinical Psychiatry she went to bed, had palpitations, and felt so wretched that she would risk anything to get herself more, in all sorts of underhand ways. " I would have stolen," she says herself ; " a. morphinist has no sense of shame." She said that her daily dose amounted to about I gramme. We therefore administered a little more than one-third of this dose at first, and then reduced it pretty quickly. The very first night there was great restlessness, with pains in the limbs, sweating, and oppression. The patient complained, " You can form no idea at all of my torment." She was irritated with the doctors, and said that no one could help her, " even if an angel came down from heaven !" On the seventeenth day, when she was only getting 0*04 gramme of morphine, she began to see ants on the sheet, and to hear her husband reproach her for having smashed a window- pane, without any cause, two days before. She was very much dazed, talked incoherently to herself, saw the d3^e-cock standing open in the tannery at home, and the dye running away, and swept lice and other vermin off her bed. At times she was quite clear, and afraid she was going crazy ; she felt as if she had a thick board in front of her head. At the same time there was a coarse tremor in her hands. Often she did not know where she was, addressed the doctor as " thou," and was frightened, and sometimes apprehensive, sometimes in a humorous mood. On pressure on her eyes she saw water, but no other hallucinations of sight could be produced. On the other hand, she begged for a screen, so that she might not see a tall man, who held out a shield to her, inscribed with the words, " Injections are not allowed." This delirious condition lasted, with frequent fluctua- tions in severity, for about a week, and the daily dose of mor- phine was only reduced by o-oi gramme during that time. The patient has now been clear again for three days, but is still unreasonable and irritated. We expect to finish the withdrawal in two or three days. The prognosis of this case is far worse than the last, on account of the much greater quantities of morphine the patient has taken for a long time, and also on account of her instability and weak- ness of will, which has partly been produced by the abuse of morphine, but also existed in part before. Her wish to be freed from her slavery to the poison was at once extinguished by the first symptoms arising from its withdrawal. Besides this, her longing for the drug has led her to actions which are morally Morphinism and Cocainism i 89 very reprehensible, such as, unfortunately, are not unusual in morphinists when the morphia craving comes over them. This loss of moral fibre in all questions in which their malady comes into consideration shows the deep-reaching influence of morphine plainly enough, in spite of its slight effect on the memory and the action of the understanding.* The withdrawal has been made difficult in the present case by the appearance of the peculiar delirious condition. Such, and other similar disturbances, are not very uncommon in morphinists, but can hardly be referred to the effect of the poison itself. In our present case the picture of disease points with the greatest probability to an alcoholic origin, and our patient has admitted that she has often had recourse to alcohol to relieve her sufferings. Alcohol is often employed by the doctor himself to make the with- drawal of the morphine easier, with the regular result that patients use both together. Cocaine is no less a favourite, and was long cried up as the true remedy for morphinism, until it was recognised that it is far worse than morphine. Our present patient was given cocaine seven years ago for a few weeks by a doctor. A feeling of apprehension and restlessness set in between a week and a fortnight later. She heard people talking about her, and her husband scolding her, and thought she was standing on a high tower, from which an angel was going to throw her down. It was only when she left off the cocaine that these hallucinations disappeared. A mechanical dentist, aged twenty-six, who came to us from a well-known institution for the cure of morphinism, has been through very similar experiences. He had been a morphinist for some years before he entered the institution eight months ago. He got on very well for the first two months, until he had come down to a daily dose of 0-02 gramme. Then, when the first symptoms arising from the withdrawal set in, he used a gramme of morphine, which, like most morphinists, he had reserved for an emergency. He w.:- able to deceive the assistant-doctor, for " he had not had experience enough to see through a mor- phinist." " Most of the patients cheated, and I knew it perfectly well, but they just pretended before the doctor." Later on he had an attack of pleurisy, during which he says the dose was increased again to i gramme a day. Later still a fellow-patient, "^ According to information given by her husband, the patient takes no morphine now, six years after her discharge. 190 Lectures on Clinical Psychiatry who also injected to relieve the symptoms arising from the with- drawal, gave the patient morphine repeatedly to insure his silence, so that the cure made absolutely no further advance. He was now sent away by the manager of the institution, who told him, as he says, that the cure evidently could not be carried out. The patient helped himself over the last part of the time, during which he got no more morphine from the doctor, by drinking " opium-cognac " in the chemist's shop, and also bought a bottle of morphine and cocaine solution, of which he used part, and kept the rest for his journey. Cocaine had been added to the morphine by his doctor to make the injections less painful. When he went away, the patient found, to his dismay, that he had left his morphine in the institu- tion. He tried at once to make up his stock at the chemist's, but only got 0-13 gramme there. " because they had begun to suspect that he was a morphinist." Under these circumstances, he went back secretly to the institution, and there got a dose of an equal amount from the head warder. Having prepared himself for the journey by some powerful injections, he grew very sleepy on the way, and finally fell into the hands of a sharper, who robbed him of all his ready-money and his watch. When he went to the police about it, he gave them the impression of being ill, was sent to the infirmary, and fell into a state of delirious confusion and excitement there, which led to his being transferred to our hospital a week later. On his admission, the patient was not clear about his surround- ings and his position, and understood us with difficulty and imperfectly. Yet he showed considerable loquacity, and related his recent experiences, continually digressing and losing the thread. He also had numerous hallucinations, which he fully described to us afterwards. In the infirmary he saw cats, mice, and rats jumping about in the cell and nibbling his legs, so that he hopped backwards and forwards screaming ; he felt their teeth. It was spiritualism, and they had come through the wall by hypnotism. The bed-clothes turned into two men, of whom one was dissected. There were also hallucinations of sexual import, and he thought that a murder was committed. The troops shot, and the fire-engine played till the water stood a foot deep in the cell. Here at the hospital the patient saw fish in the bath- water, and heard shooting and voices in the passage. Except for sensitiveness to pressure on the great nerve- trunks, tremors of the Morphinism and Cocainism 191 tongue, several fresh abscesses, and symptoms of acute gastric catarrh, there was no very striking physical disturbance. The pupils were not contracted, although the patient had had 3 or 4 centigrammes of morphine regularly for the last few days. The actively-excited and diffusely-chattering patient was at once put into a bath, and, after his stomach had been washed out, an abundance of fluid nourishment, small doses of morphine, and some caffein were given with the tube. His condition im- proved quickly in the course of the next few days, and he began to take food himself. The hallucinations disappeared, and he took a correct view of those he had previously seen. He was given his last dose of morphine on the fifth day. The symptoms arising from the withdrawal — sweating, yawning, and sneezing — were only moderately severe, but the patient still remained rather confused and obtuse. His mood was apprehensive, and occa- sionally irritated and threatening. In the numerous composi- tions he wrote, besides great diffuseness and want of connection, there appeared omissions, repetitions, and transpositions of letters and words, and also uncertainty and haste in the indi- vidual characters. But all these disturbances soon disappeared. The patient's weight rose 6-5 kilogrammes, and his sleep returned, so that you see him before you to-day in very good condition, after six weeks' residence in the hospital. Except for the injec- tion scars, there is nothing at this moment to remind us of the illness he has been through. He has good insight into his malady, is full of confidence for the future, swears that he will never have recourse to injections again, and begs for his discharge, which is also urgently demanded by his mother. After what I have already said, you will understand that we accede to this demand with a heavy heart, and only because we have no right to resist it. In reality, the time is far too short to guarantee a permanent cure with any certainty.* A very remarkable feature of this case is the delirious condition, which lasted about ten days, and reminded one strongly of alco- holic delirium. It is quite possible that alcohol in the form of brandy, and " opium-cognac," employed to make the cure easier, have played a certain part. Some features of the delirium, how- ever, point rather to the action of cocaine. Among these I count the long and dragging course of the disturbance, the * Unfortunately, I have been unable to obtain any information about the subsequent fate of this patient. 192 Lectures on Clinical Psychiatry hallucinations of feeling — i.e., of being nibbled— and the sexual adventures, but particularly the patient's loquacity, eager writing, and diffuseness, which we do not usually see under this form of delirium tremens, but find almost invariably in cocaine- poisoning. But the parts which the two poisons, working side by side, have played in producing the delirium cannot be distin- guished with certaint}'. We can only say that that particular condition was not produced by the morphine. What all these cases teach us is the heavy responsibility for the existence of morphinism which falls on the medical profession. It is true that members of this profession itself are by far the most frequently found among morphinists. But it is precisely the morphinistic doctors who go about most inconsiderately with the poison, although it is they who should see most clearly that it almost certainly destroys the happiness of life. Finally, you may see that it is an easy thing for any morphinist to get the drug he craves for anywhere. Our legislation has so far been powerless against this evil. The only real preventive of mor- phinism consists in every doctor's clearly realizing the grave responsibility which he incurs by the continued administration of morphine. LECTURE XX FINAL STAGES OF GENERAL PARALYSIS OF THE INSANE Gentlemen, — I think that our best guide to the clinical meaning of the various morbid conditions with which we meet is their iermination. We have had evidence enough before us to show how conditions of the most diverse kinds may alternate with one another in the same disease, so that it seems impossible at first to recognise their real connection. But when the more transient concomitant phenomena have run their course, the essential disturbances become more and more distinct — at least, in chronic and incurable cases. If we have clearly understood them, we can recognise the permanent and fundamental features even in those states in which they seem at first to be partly obscured by much more striking but only transitory disturbances. It is the termination of diseases, then, which will best enable us to form a judgment as to what symptoms are clinically important and what are not. But even if we entirely disregard the question of clinical grouping, a purely empirical knowledge of the termina- tion of diseases must be of the greatest value to the physician, as it gives him the power of predicting the further course of his cases. On practical grounds this is a problem of almost greater importance in alienism than in other branches of medicine, and in the impotence of our attempts at treatment we must often find our only satisfaction in solving it. The first disease to be recognised as a unit, on account of the regular law of its development and in spite of the variety of its forms, was general paralysis of the insane. In this disease the delusions of grandeur and insignificance, the excitement and depression, the delirium and hallucinations, all terminate in a peculiar mental weakness of extreme intensity, with physical 193 13 194 Lectures on Clinical Psychiatry enfeeblement. The end is everywhere the same, when no inter- current events occur to bring it on prematurely. And the numerous cases in which simple paralytic imbecilit}' exclusively, or almost exclusively, dominates the picture show that the dis- turbances w'e have mentioned as being more obvious are not in reality essential, but are rather accidental or accessory pheno- mena of the course of disease. If you look at the engine-man, aged forty-one, whom I will show you now, you will very soon see that he is demented in a high degree. It is true that he gives slow and laborious answers to questions, but he does not know exactly where he is, and thinks he is " in a hydropathic where there are nervous patients." He cannot tell the present month and year, gives his age incorrectly ,^ cannot say when he was married, or how long he has been here, and does not know the doctors' names. His general knowledge proves to be extremely defective. Although he was a zealous newspaper reader, he says that Wurtemburg is a republic — " The Crown Prince will be President — George, or whatever his name is." The Battle of Sedan was fought on September lo or 12. Other battles in 1870 were those of Koniggratz, Belfort, and Saarlouis. He makes man}' gross mistakes in doing sums, but at the end he says with satisfaction that he is good at mental arithmetic. He is quite contented to stay here ; it suits him very well, though he does not consider himself insane. But he had to spend many hours together in great heat at the paper-mill where he used to work, and that has made him nervous. His mood is indifferent, and he does not worry at all about his position, but lets himself be managed just as we please. Even in this short conversation, not only are the patient's weakness of judgment and dulness obvious, but the profound disturbance of memory and of the sense of time, place, etc., comes out so strongly that we are led at once to suppose that this is a case of general paralysis of the insane. The physical examina- tion shows flabby, expressionless features, with unequal defini- tion of the labio-nasal folds. When the tongue is put out, it trembles strongly, and there are accompanying movements of the whole face and of the muscles of the neck. The right pupil is more dilated than the left, and both are inactive to light. The hands tremble, and their muscular strength is impaired ; the movements are awkward and unskilful. The tendon reflexes are exaggerated, and there are signs of ankle-clonus. There is Final Stages of Paralysis of the Insane 195 slight swaying on standing with the eyes shut. The patient takes no notice of a sharp needle-prick I give him during our con- versation, and is quite surprised when his attention is drawn to the needle sticking deep in his hand. His gait is rather clumsy and his writing unsteady, and his speech is much disturbed. There is obvious syllable-stumbling when he repeats test-words. Moreover, when objects are shown to him, he is often unable to say what they are, although he knows the things themselves quite well, and agrees at once when he is told their names. There are also signs of aphasia. You see that the result of the examination has fully borne out our supposition. The whole picture before us has all the essential features of general paralysis, though without the delusions and changes of mood we observed in former cases. Possibly the symptoms were more marked before the present condition set in, but that is not to the point here. The patient is illegitimate, and has two distant relations, who are insane. He was quite well until fifteen months ago, and was a temperate and industrious workman. He is married, and has had a child. The illness was first noticed after a tire, but the patient suffered from double vision for a short time four years ago, and was sometimes unable to retain his urine then. After the fright, headaches, sleepless- ness, want of appetite, constipation, loss of memory, and depres- sion set in. Sometimes the symptoms grew better, and the patient worked in the intervals, but did so hurriedly and with some excitement. When he was finally admitted here four weeks ago, he had slight attacks of weakness and stupefaction, during w^hich he grew giddy, was obliged to sit down at once, and showed marked aphasia. He generally recovered in a few hours. Lues is denied by the patient, though gonorrhoea is admitted. But the previous occurrence of double vision makes a luetic foundation for the disease very probable in this case also. By this previous history, an addition is made to our picture of slight but unmistakable paralytic attacks. Such attacks and transitory aphasic disturbances are very often the first signs of incipient general paralysis. Psychically, however, the patient has from the first simply presented a picture of gradually in- creasing imbecility, if you disregard the emotional depression which forms the almost invariable introduction to the illness. This kind of onset of general paralysis of the insane, generally called the demented form, is, in my experience, by far the most 13-2 196 Lectures on Clinical Psychiatry common, although it comes before the nerve-specialist more often than the alienist, on account of the absence of grave mental sjonptoms. The cases belonging to this group, however, are far from being all of the same kind. The greater part must certainly be counted among the most severe forms of general paralysis. The deepest mental enfeeblement, and even the termination of the disease, are often reached surprisingly quickly, occasionally within a few months, so that one is sometimes inclined to suppose that the disease must have existed for a long time before it was recognised. But I have often been able to satisfy myself that this opinion is wrong. The further course of the illness, which is usually attended by frequent paralytic attacks, and marked by the absence of remissions, may also be very rapid, and in nearly a fifth of the cases death follows within the first year of the illness. On the other hand, there are a few cases, running their course essentially under the appearance of simple dementia, which make very slow downward progress. Unfortunately, we know nothing whatever about the cause of these differences. In our present case, the first traces of the disease go rather far back ; at least, we may connect the double vision and cystic disturbance, four years ago, with the malady which appeared more distinctly afterwards, as such symptoms often precede the palsy. In view of the slowness with which the more severe disturbances have followed those which were the first to appear, we may perhaps be justified in expecting the disease to run a rather protracted course in our patient.* In order to convince you that a state of simple dementia in general paralytics may form the termination of symptoms of quite another kind, I will show j^ou a merchant's wife, aged fifty- two, who has been in the hospital for six years. The patient, quite bent, comes in with painful, shuffling steps. The answers she gives to our questions are almost incomprehensible, yet they show that she knows where she is and can tell the names of some of the doctors who were formerly here, but has no clear idea at all of her position or of time. She cannot tell her age, or the year of her marriage, or her children's names, does not know how long she has been here, and considers that she is quite well and never has been ill. Her mood shows indifference, though * The patient died three years and nine months after the first appearance of the psycliical changes. Final Stages of Paralysis of the Insane 197 sometimes she seems rather exalted or irritated. The mention oi her husband and children makes no particular impression on her. Yet isolated expressions that she uses still show traces of her former knowledge. She interpolates scraps of Italian and French in her talk, and caps the name of Artaxerxes, mentioned before her, with the words " Hannibal " and Carthage. She can still read fairly well, but does not understand the sense of what she has read. Now and then she offers some resistance, refuses to give her hand, and complains in a scolding tone that all that she possessed has been stolen. She behaves quite apathetically in other respects, and does not trouble about what goes on around her. Physically, the flabbiness of her vacant features and the severe disturbance of speech are very noticeable. Her articulation is very indistinct ; the individual words are pronounced jerkily, with an effort which often results in the omission or transposition of letters. When the tongue is put out, it trembles almost spasmodically, and there is a distinct quivering of the lips. The right nasal fold is less marked, and the right pupil very much larger than the left, while both pupils are quite inactive to light. Sensibility to pain is much reduced. The tendon reflexes are much exaggerated. The diagnosis of general paralysis of the insane is, of course, confirmed by the result of the examination. Here, too, we see all the appearances characteristic of this disease in their most definite form, united towards the end of the illness in a certain degree of purity, without non-essential disturbances. The patient, who belongs to an excitable family, was always very active and irritable. She was highlj^ talented in many different directions. She aborted three times, and has a daughter, who suffered while still quite young from a creeping paralytic affection of the brain and spinal cord. The beginning of the patient's paralysis can be traced back eight years to a transient loss of speech. In the course of the following year a fundamental change gradually appeared in her whole character. She became very irritable, flighty, and forgetful. She was negligent of what she did, left out letters and words in her correspondence, lost her knowledge of languages and her execution in singing, also her artistic taste, offended against good manners and propriety, and became rude and rough to her relations. Her speech became indistinct and slurring. In this condition the patient was admitted to our hospital. 198 Lectures on Clinical Psychiatry and even then showed marked mental weakness. She now began to express quite senseless ideas of grandeur. At first she only had a property in Italy, an admirable voice, and wonderfully pretty children, but later on she gave away 1,000 litres of red wine and champagne, had 5,000 chests full of golden clothes, many millions in gold, thirty beautiful fingers, her voice had a compass of four octaves, she had three children by Bismarck, was two months pregnant by the Emperor, felt four-footed children in her womb, had had seventy children, etc. She repeatedly had slight paralytic attacks, with giddiness, vomiting, and great flushing of the head. Her weight rose, with a gigantic appetite, from 53 to 8o*5 kilogrammes in the course of fifteen months. Then a fall began, rapid from the first, and finally almost precipitate, to 45- 5 kilogrammes. At the same time a state of violent apprehensive excitement set in. The patient became quite bewildered, could not eat or sleep, resisted every influence, threw herself about in the greatest restlessness, tried to inflict injuries on herself — for instance, to tear out her tongue and her teeth — and expressed a number of the most senseless ideas of depression. She was dead ; she could not swallow ; robbers were coming ; her husband was slaughtered ; her children were in the water-closet ; 100,000 Empresses were shut up in the fuel -house ; she had been robbed of 10,000 handkerchiefs ; her breasts had been cut off, her blood drawn off, etc. It was not till after some months that the patient recovered very slowly from this highly critical condition, and her weight has never risen much above 50 kilogrammes at anytime in the sub- sequent course of her illness. It now became evident that both the feeble-mindedness and the physical disturbances had made a very considerable advance. The patient had become quite unintelligent and dull. Since then, however, her condition has remained much the same.* The course the disease has taken here is in complete opposition to the almost invariable rule that general paralysis leads to death in three or four years. Cases of far longer duration are, however, by no means uncommon, and the possibility has to be reckoned with that the disease, under * The patient is still in the hospital, the disease having lasted for more than twelve years. She is completely demented, and physically quite decrepit. There is slight contraction of the right arm, and an aneurism of the aorta seems to have developed. The illness of her daughter, who is now dead, was shown by the autopsy to be juvenile paralysis, such as may be caused by congenital syphius. Final Stages of Paralysis of the Insane 199 very favourable circumstances, may become altogether stationary. For the present, in such "stationary" cases emphasis must always be laid on the probability of a mistake in the diagnosis, especially the confusion of general paralysis with syphilitic lesions of the cortex. In this particular case the clear definition of the clinical picture will hardly allow of such an assumption. Un- fortunately, the doubt which certainly did arise could not be set at rest by microscopical examination of the cerebro-spinal fluid, an aid to diagnosis which is generally decisive in dis- tinguishing arterio-sclerotic, traumatic, and katatonic dementias from general paralysis. While the fluid obtained by lumbar puncture in the sane contains hardly any cells, numbers of lymphocytes are regularly present in general paralysis. This result was found in our patient, but as syphilitic diseases, so far as they extend to the pia mater, also produce an increase in the lymph cells, it gives no answer to the question before us. You see that a number of conditions of different kinds have succeeded one another in this case, the last being the simple de- mentia of general paralysis. This will show you that the current division of this kind of paralysis into the depressed, agitated, and demented forms, and so on, does not present a series of definite groups, but only gives the general outline of a classification of the material for study. Unfortunately, in the present state of our knowledge we have nothing better to put in its place. The weight in this case has corresponded more or less to the changing conditions. This is in agreement with general experience. It is very common for the weight to rise enormously in certain stages of paralysis, and then to fall continuously later on, without any corresponding change in the quantity of food which is taken. This is so common an experience that it can hardl}^ be accidental. Indeed, I think there is no doubt that we see revolutions in the physical economy here which are somewhat similar to those observed in alcoholism and diabetes. These phenomena may therefore show that general paralysis is not purely a disease of the brain, but is associated in its course with changes in the whole body. And I think that the tendency of paralytics to bed- sores and to haematoma on the ear, and the remarkable brittle- ness of their ribs, are to be interpreted in the same sense, as well as the frequency of albumin in the urine and of other vaso-motor disturbances. The case before you is also an example of general paralysis of 200 Lectures on Clinical Psychiatry the insane in women. Its course is different in no essential point from what we have observed in men. It has sometimes been said that the disease runs a slower course in women, and that the delusions are less extravagant. But this is only the result of the greater freedom of a man's position, giving him the opportunity of doing himself more serious injuries, which may have an un- favourable effect on the course of the disease. The abortions which have taken place, and perhaps the illness of the child, make it seem very probable that syphilis has played a causal part in this case also. But the proof of this cause is generally far more difficult to trace in women even than it is in men. Lastly, a way-bill carrier, aged fifty, whom I am obliged to have brought before you in bed, as he has long been unable to walk, shows you the final and most aggravated stage of the disease. The patient has lain insensible since yesterday, and does not respond when he is spoken to or even pricked with a needle. His head is turned over to the left, and the half-opened eyes are also fixed in that direction, and are rotated a little upwards. The pupils are dilated and inactive to light. The features are flabby and sunken, and the lips are dry and covered, like the tongue, with slight sordes. The breath has the half-putrid, half-sour aromatic smell which is common in starving lunatics, and is due to the presence of acetone. The breathing is superficial and slow, the pulse small and frequent, and the temperature rather high. You notice an obvious spasm in the limbs when you try to bend them, particularly' on the right side, and the knee-jerks are very pronounced. If we wait a little while, you will see the eyes suddenly turn quite to the left. Then there is a jerking move- ment of the head to the left, succeeded in turn, after a short pause, by clonic spasms of the head. At the same time, the spasm in the limbs increases, and also ends in slight twitching, especially on the right side. The whole movement only lasts a few minutes, and then the patient lies motionless again. What you have before you is a paralytic attack. It differs from an epileptic seizure in the comparatively slight signs of convulsions, combined with the most profound loss of conscious- ness, and particularly in the unequal manner in which the different muscular groups are affected. In this respect it resembles cortical (Jacksonian) epilepsy, as distinguished from ordinary epileptic fits, in which the convulsions are symmetrical. There are, however, paralytic attacks which are exactly like epileptic Final Stages of Paralysis of the Insane 201 seizures. Others resemble apoplexy. The patients suddenly fall to the ground, breathing stertorously, and either die at once or wake up after a little while with one side disabled, and often with aphasic disturbances. Very sudden recovery from these s\TTiptoms must i.]ways arouse a suspicion of general paralysis. We have already adverted to the slight attacks of giddiness and fainting, which often betray their fatal import by traces of aphasia. In our patient the attack, which really consists of a series of single attacks, has already lasted for thirty hours. This may go on for some time under certain circumstances — for eight or ten days, or even longer — but the danger to life grows greater every day the attack continues.* Death is not, however, as a rule, the immediate result of the affection of the brain, but is generally caused by septic pneumonia. The saliva, mingled with decomposing products in the mouth, trickles unhindered through the quite insensible larynx into the lungs, producing lobular inflammation. Another danger arises from the bed- sores, which can only be avoided in a patient who is quite helpless and continualh' dirties himself by ver}' careful nursing and, best of all, by the use of the prolonged bath. As the patients cannot swallow, they cease to take any nourishment, and it is best to leave them almost fasting. But if the attack lasts longer than two or three days, recourse must be had to artificial feeding, regulated by the general state of nutrition. Previously to this, the attempt may in an}^ case be made to introduce some water into the body by large injections of saline solution into the rectum. Where there has been dangerous heart-weakness, we have also employed subcutaneous injections of common salt. The cavity of the mouth must be kept as clean as possible by frequent washing with disinfectants, and attention must also be paid to the regular evacuation of the bladder and rectum, which often cease to act. Even with the most careful nursing, a well-defined paralytic attack is always a most serious occurrence, and though it may be possible to maintain life, one generally finds that the patient's dementia is markedly increased. Our patient has already had a paralytic attack three months ago, lasting for several days. It is a year and nine months since he first fell ill. It was noticed that his memory was failing, and that he made many mistakes in arithmetic, and could not write * The patient died next day during the attack. 202 Lectures on Clinical Psychiatry or speak properly. Although these disturbances quickly in- creased, he did not feel ill. It was only when he had the attack that he was brought to the infirmary, where even then he proved to be quite vacant, showed considerable restlessness, and de- veloped some slight ideas of grandeur. He came here seven months ago, and was then completely demented, with a most pro- nounced disturbance of speech, chiefly in the form of a tendency to reduplicate unaccented syllables. This is a disturbance belonging to the group of what has been called recurring utter- ance. He was also plainly aphasic. Thus, he called firearms " woods, little wood, wooden chest," and a watch-key " watch- emperor," " watch-winder." His pupils still reacted a little. His general reflex excitability was so greatly increased that, on sudden movements being made against his face, his whole body shrunk at once. If he was placed on a chair so that only his toes touched the ground, his legs immediately began to rock up and down regularly by the production of ankle-clonus. Walking and standing soon became impossible as the result of weakness and a spastic condition of the legs, and, in spite of the patient's taking abundant nourishment, his weight fell continuously, 10 kilogrammes in all. He became more and more demented and helpless, and was permanently wet and dirty. Latterly there has been loud and continual grinding of teeth, which is often observed in the last stages of general paralysis. This complete extinction of mental life, in conjunction with the most severe physical infirmity and the signs of disablement described, forms the regular termination of the illness, if it is not first cut short by intercurrent contingencies. Considering the enormous number of patients who end unfortunately, we hardly have the right to count in practice on the possibility we have mentioned of recovery, or even of the arrest of the disease. Yet the unfavourable prognosis we have given not infrequently seems to break down, owing to its being founded on an error in diagnosis. We have already mentioned a number of wide- spread affections of the cortex which during life may simulate the clinical picture of general paralysis in a more or less mis- leading way. Besides these, there are most probably many other incidents of disease, still unrecognised by us, which re- semble general paralysis in their manifestations, but run an entirely different course. Pathological anatomy must act as our guide in deciding these questions. Final Stages of Paralysis of the Insane 203 Pathological anatomy has already shown that the foundation of general paralysis is formed by widespread disturbances of all the important constituents of the cortex — the cells, the fibres, and also, it seems, the fundamental gray substance between the cells — also by a great increase of the glia, the formation of new bloodvessels, the establishment of plasma cells in the lymph spaces of the vessels, and the appearance of numerous rod or bacillus cells. The final change is shrivelling of the cerebral cortex, with more or less complete destruction of those parts of the texture which are generally considered to be the psychological tracts. The morbid changes also spread over many other parts of the brain — the great basal ganglia, the nerve-pith, and even the spinal cord, in which the lateral and posterior columns seem to be more particularly affected. Lastly, the pia and dura mater, and apparently a great many of the organs of the body, are sympathetically involved. But on this last point our knowledge is very imperfect. The general picture of all these changes may be considered so far diagnostic of general paralysis that it is possible, from the anatomical examination, to recognise a number of pictures of disease as being " atypical " paralysis, which show very im- portant deviations from its recognised forms on account of the unusual extent of the changes. We are also in a position to separate all the unimportant admixtures from the general idea of paralysis from an anatomical point of view. The clinical definition is still often doubtful, but it may well be expected that in time we will learn better and better, even in the patient's life- time, to distinguish the picture of general paralysis arising on a syphilitic soil, which undoubtedly forms the bulk of the cases observed, from such outwardly similar forms as present another mode of origin, and therefore often have a different course and termination. LECTURE XXI FINAL STAGES OF DEMENTIA PRiECOX Gentlemen, — In general paralysis the inexorable results of the disease make it comparativeh' easy for us to recognise without post-mortem examination — at all events, at the end — that all the different forms of the malady are to be traced back to a uniform process of disease in the cortex of the brain. With other forms of dementia it is a far more difficult question. In these the final conditions are in no way so similar that the homogeneity of the very manifold symptoms is made obvious by them alone. Not only do all possible gradations present themselves, from cases of the most favourable kind to those of the gravest feeble- mindedness, but also sometimes one and sometimes another relic from the earlier stage of the disease can give to the final condition its special colouring. In this way there arises, not only during the course, but also in the results of insanity, an absolutely confusing wealth of form. I can still only too well remember the perplexity with which I faced, throughout very many years, the vast number of states of mental weakness harboured by every large asylum. Their manifold manifestations were to a certain extent grouped together, but, in spite of all variety in outward form, definite characteristic features recurred with surprising uniformity. We are given the key to this confusion by the histories of individual patients. We learn from them that with the great majority of more or less feeble-minded patients those appearances which we have learnt to recognise in dementia prcBCOx have existed previously, even if with varying degrees of distinctness. But they further teach us that where dementia has been induced by different processes of disease, upon closer investigation the particular nature of the malady still remains recognisable, even 204 Final Stages of Dementia Prascox 205 in the final conditions. Therefore it is a fundamentally soluble problem, if at the same time a difficult one, not only to be able to predict, in the beginning of a mental derangement, the further course and result of the malady, but also inversely to form con- clusions a posteriori upon the earlier stages of the disease from the final condition. It is not one particular form of dementia with incidental variations which constitutes the result of the most varied kinds of uncured mental disorders, but every form of insanity, if not cured, leads to a final condition peculiarly its own. It is true that this peculiar condition invariably shows itself in the essential symptoms of the disease alone, whereas the inci- dental accompanying phenomena may greatly change. Our knowledge of what is essential is, unfortunately, at the present time very incomplete, so that often enough we must remain in doubt as to the meaning of a particular final condition, should we be without the pieceding history. Still, even now, in a considerable number of cases, the careful observation of clinical symptoms makes it possible for us to trace out at least a rough outline of what has gone before from the final stage of the malady. The woman, aged fifty-seven, who will serve as a first example, is quite collected, clear as to time and surroundings, and gives information with great loquacity. She at once begins to lay stress upon the fact that she is quite well and ought not to be in the hospital, and demands her immediate release. Her husband would appear to be insane for having brought her there ; he has kept company with other women, treats her badly, and spends a great deal of money, while she has alwaj'S been an exceedingly well-behaved and thrifty wife. The neighbours had insulted her, a traveller had made an ill-mannered gesticulation in her presence. When she went to the district office to get a certificate of respectability, she was suddenly obliged to laugh, although she was by no means in a laughing mood ; it had been the same in the asylum when they had examined her with mirrors. She is treated badly by the persons employed in the establishment ; her fellow-patients repeat things they have been taught to say, and they spit in her wash-hand basin. The bed burns at night in a strange way ; there must be something put in the mattresses. The doctor has damaged her arm ; something, too, has been done to her eyes. The patient produces these statements fluently, but in an affected " High German " way of speaking, and with all manner of forced expressions. She obeys orders only after 2o6 Lectures on Clinical Psychiatry some persuasion, says it is not necessary to give her hand, but in the end extends it stififly towards the doctor. Of physical disturbances we only note a ver}^ pale and somewhat puffy appearance, with a small and frequent pulse (120 beats). On further interrogation, it appears that the patient has already been several times in our hospital, and can still quite well remember all the details of importance of her previous visits. Her mother was morbidly religious ; she herself married at twenty- two years of age, and had nine children, of whom six are dead. In her thirty-eighth year she had t3-phus, soon followed by the beginning of the mental derangement. Mention must be made that at that time she was in the first months of pregnancy. She thought that people spoke about her, and looked her impudently in the face, spat in front of her, made unbecoming allusions, and sought to entice her into making incautious remarks about the Emperor, so as to be able to inform against her. As in conse- quence of this she did not eat, and slept badly, she was brought to the hospital. Here she felt herself persecuted in the same manner, and had several violent attacks of screaming, in which she tore out her hair and made faces. For some weeks she was quite mute, and always took up the same position with an imbecile expression of face. Even with the setting-in of improvement she remained discontented, grumbling, and un- intelligent, and would not admit that she had been ill. After nearly six months' residence in the hospital, she returned to her family, but there she proved irritable, absent-minded, and forgetful. Seven or eight years ago her condition gradually became worse ; she was dull and inactive, spoke little, expressed the old ideas of persecution, and ionv and a half years ago suddenly tried to poison herself with the heads of matches, and also later on to open her arteries. Her husband, even at that time, had been struck by her affected way of speaking, for this had not formerly been her habit. When she was again brought to the hospital, she quickly sank into a deep stupor. Although she was clear as to time and surroundings, kept herself tidy, and ate of her own accord, she sat in bed quite speechless for nearly a year, much bent forwards and with firmly-closed eyes, opposing every interference with the most obstinate resistance. If after much trouble one succeeded in laying her down, she at once sprang up again. To open her eyes proved quite impossible. On sticking a needle Final Stages of Dementia Prscox 207 into even the most sensitive places, she reacted at most by a shght blinking or flushing. Visits from her relations made not the slightest impression on her. At meals, she dipped the point of her nose into her soup, though she guided the spoon quite slowly and properly to her mouth, but stopped directly anyone came into the room. Eventually there were sores from pressure between her firmly-clasped fingers. The body-weight sank about 16 kilogrammes. The patient was now taken to another asylum, where she remained in the same condition for nearly a year longer. From this she woke up quite suddenly, and demanded her im- mediate discharge, for she was perfectly well. Even now she regards her strange behaviour as in no way morbid, although she admits all the particulars. She had not spoken because she thought she would go home the sooner if silent ; she complains bitterly that someone had at that time stuck an iron (the pin) into her forehead, and had knocked her over. After the cessation of the stupor, the patient returned to her husband two and a half years ago, but was very irritable, especially at certain times, and went to different lawyers about bringing an action on account of shutting her up in the asylum, for which she demanded 30,000 marks as compensation. Then distinct hallucinations of hearing and feeling gradually supervened. Her husband and people in the street mocked at her ; there were infernal machines in the bed and in the chair, and also in the stove, through which someone let loose rays upon her. Horrible voices resounded from her own body, out of the water-pipes, and in the barking of dogs, so that she had no rest night or day, and threatened to starve herself. All these things the patient now simply denies. She only admits that she heard voices, also that she is breathed upon and blown upon at night ; she has never been guilty of Ihe majeste. She keeps almost entirely apart from her fellow-patients, but occupies herself industriously with sewing, and writes numerous letters of uniform purport, in which she importunes her husband to take her back home. It will be evident to you, in consideration of the long-continued, sharply-defined negativistic stupor, that in the present case we have to deal with katatonia. Also the first development of the disease and the appearance of a depression, with ideas of persecu- tion and hallucinations of hearing, correspond with this opinion 2o8 Lectures on Clinical Psychiatry throughout. But it is a very remarkable fact, that after the first setting-in of the disease, the nature of which was plainly shown by the transitory sinking into stupor, a period followed of more than ten years, during which no more striking symptom existed than a slight change in manner. That this condition certainly did not mean recovery is proved by the subsequent severe relapse. It is precisely this observation that ought, like so many similar ones, to urge us to further caution in judging of the improvement and cure of katatonic patients. The second attack is a good illustration of the sudden disappear- ance of stupor after apparently far-advanced feeble-mindedness, but at the same time it shows the complete want of insight into the disease, and the inability of the patients to give any kind of information as to the motives for their strange behaviour, or even to recognise the morbidness of it. From this, in particular, it becomes clear that katatonic stupor may not be brought about by hallucinations and delusions, as is still sometimes supposed, but depends upon an altogether primary disturbance of the will. Finally, the present condition of our patient is that of a peculiar kind of feeble-mindedness, with weakness of judgment, emotional dulness, irritability, absurd behaviour, and indications of nega- tivism, while comprehension and memory are little injured, or not at all. At the same time, hallucinations exist in the province of feeling and hearing, as well as the delusions connected with them, and from which they are distinguished only in degree, as we have already learnt to recognise in the paranoidal forms of dementia praecox. This condition is to be looked upon essentially as a final one ; deterioration, stupor, or excitement, and further mental weakness are still very possible, but one must no longer count on a substantial improvement.* An essentially different picture is presented by the woman, aged thirty-six, whom you now see entering with rather a shame- faced smile. She sits down without looking round, gives single monosyllabic answers only to pressing interrogation, and stares mostly in front of her with a vacant expression of face. On being asked where she is, she says " In the room," but admits having been here four years ago ; she calls me " the gentleman from Frankfort," and says that she has seen one of the other doctors before ; he was always running through the room. She does not * The patient was sent to a nursing asylum, where she again sank into stupor and died after some years. P'inal Stages of Dementia Praecox 209 know names ; says she is not ill. She gives no further informa- tion as to her condition or as to her domestic circumstances than that she has children, who are at home. She does not carry out instructions, and resists the attempt to grasp her hand. Whilst we are discussing her behaviour, she suddenly begins to speak in a quite confused manner. " WTiat do I want, then, with the old fools lying down there ? 1 can't clean them. The old creatures are lying over there. They have nothing to do with me ! They are quite old enough ; they can lie there. Some people say to lay down — to lay down or corpses." She goes on laughing, " They have said children lay corpses, but a child does not lay eggs. The people here are much too haughty to me." It is impossible to obtain an explanation of these remarks. In speaking, the patient does not look at us, but looks to one side, then keeps silence, and begins after some time to murmur to herself similar incomprehensible sentences, gradually becoming excited. Physically, the patient is very pale and badly nourished : she has nursed her child since her last confinement of eighteen months ago. Sugar was found transitorily in the urine. In the clinical interpretation of this condition we have, above all, to consider the peculiar, irrelevant talk of the patient, which is evidently to be taken as confusion of speech, as no reference to the questions directed to her or to other incidents in the sur- roundings can be seen in it. At the same time, the patient is certainly in a position to understand simple language, as indi- vidual answers prove. I will mention in addition that at times she occupies herself in quite an orderly way in the work of the ward, though it must be admitted she talks all the while in an absolutel}- confused manner. Then, the indications of negativism must be borne in mind — the refusal to give her hand, her looking away in talking, her silence to questions which she is in a position to understand, and, finally, the complete indifference and apathy of her whole behaviour. The patient is demented, and presents a series of sjnnptoms with which we are familiar from the discussion of katatonia. We shall scarcely err, therefore, in recognising her condition as the outcome of uncured katatonia. In her previous history we have to note that a step-sister of the mother was feeble-minded. Four years ago, in connection with a confinement, the patient had slight convulsions, with palpitation of the heart, without loss of consciousness. Three years ago, when one of the children lay ill with influenza and a removal to 14 2IO Lectures on Clinical Psychiatry another town was impending, the patient became apprehensive, worried over the future, thought she had made her husband un- happy, became negligent in housekeeping, and had to be brought to the hospital. Here she was tearful, almost mute, did not know where she was, and complained of heaviness in her head. She wandered out of bed a great deal, did all sorts of silly, incompre- hensible acts, threw plates out of the window, upset a whole dish of vegetables, and was occasionally senselessly violent without any perceptible cause. Her mood was generally indifferent, now cheerful, now irritable ; she laughed to herself a great deal, and sometimes suddenly screamed out " Hurrah !" Her talk was at that time much more irrelevant and mcompre- hensible than it is now. She offered the doctor a piece of bread, and added, " Here you have the oxen. I am an ox, am an ox ; take it, I am an ox." In this there appears still more distinctly than in what she has said to-day the inclination to senseless repetitions of the same expression, which we have so frequently remarked in katatonia. Another time she exclaimed, " I have not winked, I have not wished, I have not stolen. I fare as I have never done at home. Baking ovens are not persons." Together with the forced phraseology, one notices a senseless forming of new words, which is a very familiar accompanying phenomenon of confusion of speech. The patient was indifferent to, or irritated by, the visits of her husband. She devoured the eatables he had brought with him in a very greedy and disgusting way. Hallucinations also apparently existed — at all events, transitorily — although no further detailed information was to be learnt about them from the patient. But she spoke of a smell of death in the food, saw her brothef go out, and thought it was said that she would redeem everj' soul. Finally, one was struck by the great slowing of the pulse. After six months' residence in the asylum, the patient was taken home, contrary to medical advice. There, too, she was often violent, expressed ideas of persecution, and thought her children were being beheaded. Although she was very forgetful, she occupied herself quite well with the housekeeping, and another child was born. But latterly she was so troublesome, through having tried to break into a school and to open a grave in the churchyard, that four months ago she had again to be brought to- the hospital. Here she presented from admission the picture- Final Stages of Dementia Prascox 211 that you have seen to-day. She often expressed quite confused ideas of persecution, especially of sexual import.* During her first residence with us an attack of syncope had already taken place ; at home also there were repeatedly similar attacks with convulsions. A few attacks have lately been ob- served here. The patient sank to the ground, and rolled about with her eyes shut, without reacting to pinching or pricking, and murmured, "It is bad, my head." Short trembling and con- vulsive shocks appeared in the arms and legs, and also in the muscles of the body ; the jaws were firmly clenched. Breathing was superficial, with long pauses ; the pulse was accelerated. The pupils reacted to light. After from fifteen to twenty minutes quietness supervened. These attacks pretty nearly resemble those which we have observed in hysteria. It is possible, of course, that they may indicate hysteria ; still, it is noteworthy that the first of these occurred during a confinement, which we have certainl}' learnt to recognise as an important cause of kata- tonia. For this reason, I should like to point out that in kata- tonia we pretty frequently find attacks of this kind, and also others, reminding us more of simple fainting fits or even of epilepsy. I know a whole series of cases in which attacks of pronounced hysterical colouring formed the introduction to a katatonic illness, with grave dementia. We are certainly not as yet in a position to give an assured explanation of these clinical phenomena. An impression of almost greater dementia than that of the patient just now discussed is made by the cigar-maker, aged twenty-one, of strong build, who now sits before you in listless attitude, dully staring in front of him. On being urged, he gives his name. He knows where he is, knows the date, and recollects having been here five or six years ago, but is unable to tell our names. He does not feel ill, and says he likes home better. The patient does not show the slightest interest in his surround- ings, does not look up, does not speak of his own accord, and gives only quite short monosyllabic answers. Except for an occasional silly smile, he shows no signs of variation of mood. He carries out orders awkwardly, offers his hand in a stiff, ridiculous position, and is distinctly cataleptic. Of his lot in life, * The patient has been nine and a half years in a nursing asylum. She is demented, confused in speech, negativistic, absurd in behaviour, and at times excited. 14 — 2 212 Lectures on Clinical Psychiatry his domestic circumstances, and his plans for the future, one does not learn a word from him. But if we place this apparently completely demented patient in front of a map of the country, he is able, with quite surprising rapidity, to find any large town you like to mention ; he also does simple sums quickly and correctly. From this we see that the mental dulness and poverty of ideas now existing must be an acquired condition, for the patient, as he now is, could not possibly have gained knowledge of any such kind. If we further keep in view the want of emotional feeling, also his unnatural way of offering his hand, we are forced to adopt the decided opinion that our patient presents the final stage of dementia frcecox. It is of importance to notice that he has a somewhat puffy face, which we very frequently see in that disease. Finally, I must draw your attention to the numerous little super- ficial sores on the face and scalp which the patient has incurred through continual picking with his fingers. He has also torn out some of his toe-nails. We frequently meet with an inclination to tricks of this kind, mostly very obstinate little self-inflicted injuries, in the imbecile states of dementia praecox. There is to be noted in the previous history of the patient that two of his aunts suffered from " falling sickness." He himself had convulsions in his childhood, and seven years ago several times suffered from erysipelas. In school he was one of the best scholars, but always rather shy and retiring. Six years ago he had a fall on the back of his head. Soon after that he became apprehensive, thought someone bent over his bed at night ; the quality of his work fell off, and he made confused assertions that he had taken part in the war, and had beaten six devils to death. He became gradually quieter, absent-minded, as it were ; sometimes for amusement he would drill his fellow-workmen ; he was strikingly greedy at meals, a sjouptom very frequently noticed in dementia prascox, especially when alternating with refusal of food. On admission to the hospital five years ago, the patient, even at that time, made as mentally-weak an impression as he does now. E'ut he was obstinate, gave entirely irrelevant answers, and made statements in which confusion of speech with stereotypism were noticeable. He repeated several dozen times, " He is the ruler, heistheruler," then went on, "To kill needlessly — French. That ought to be published by ringing the bell ; I will take the bell myself." To the question, " Where are we here ?" he replied, Final Stages of Dementia Praecox 2 1 3 "With the ruler." " Of what country ?" " Of Job "—and so on. Emotionally, he was completely dull, did not trouble him- self as to his surroundings, and sat or lay about in corners, without occupying himself. After some months he became rather more active, and now disclosed an amount of information for which one would never have given him credit. But his be- haviour remained silly, his answers often senseless throughout. At times he fell into excitement, suddenly spat in the doctor's face, smashed a pane of glass, and became very quickly quiet again, without being able to give the reason for his actions. He also apparently heard voices at such times. He frequently showed echolalia ; once he made an attempt to strangle himself. After nine months' residence in the hospital, the patient returned home and began work again, but was very slow at it. He was taciturn and often irritable. Nearly a year ago he became greatly excited, frequented the public-house, threw articles out of the window, screamed out that he was bewitched, seemed to have all sorts of hallucinations of sight and hearing, hardly ate or slept at all, and on that account had again to be brought to us. Here he was collected, but demented and dull. He remembered his former residence here without being able to give details. He related in a confused way that he had been persecuted and bewitched. While for the most part he lay in bed quite apathetic, hiding himself under the bed-clothes, from time to time he fell into very violent excitement, was destructive, called out of the window, talked incoherently, was dirty, took up strange attitudes, climbed about on the bedstead, and threw out the bedding in order to place the wire-mattress on the top, threatened violence, and complained that they wanted to cut open his body and to tear out his throat, apparently on the ground of voices. After a few days he again became quieter, and sank into the same imbecile inaction as before. Physically there was no disturbance to be seen, except severe dermatography, mechanical excitability of the facial nerves, and the puffy ap- pearance of the face, but his weight showed pretty regular fluctuations in connection with the excitements.* The picture here described may serve as an example of in- numerable cases of the same kind — i.e., the gradual enfeeblement * The patient went into a nursing asylum five years ago, and from there was able to be discharged improved. He now works at home industriously, but speaks little and is easily excited. 2 14 Lectures on Clinical Psychiatry after apprehensive mood at the commencement, with the de- velopment of individual katatonic s}Tnptoms, such as in this case the confusion of speech, the stereotypism, the automatic obedi- ence, the instinctive actions and absurd behaviour, and, lastly, the continuous alternation between dull semi-consciousness and silly excitement, along with occasional hallucinations and at the same time surprising knowledge belonging to an earlier date. The -periodic excitements, in particular, are very commonly accompanying phenomena of the final stages of dementia praecox. These cases are usually to be found in vast numbers in large lunatic asylums, and, owing to their strange habits and sudden excitements, together with their self-possession and capability for work, give to those institutions their unique char- acter. But, however seemingly different the outward picture of individuals amongst these multitudes may be, the fundamental disturbances, which we have so often diagnosed, in the province of sensation and of action, are common to them all. LECTURE XXII DEMENTIA FROM COARSE BRAIN LESIONS Gentlemen, — If we have expressed the hope that it will be possible to differentiate yet further affections of the cortex from the great provinces of general paralysis, we must at the same time remark that we do, of course, already easily distinguish from paralysis those diseases of the brain which produce no extensive, but rather, I may say, circumscribed, changes in the cortex. You must, then, certainly not mistake for a general paralytic the peasant woman of fifty-eight years whom I will now bring before you. As you will recognise at the first glance, the patient is powerless on the right side. The right arm lies in a semi-flexed position close to the body ; the hand which hangs down is of a bluish-red colour, somewhat puffy and cold. In passive move- ments you notice distinctly a strong spasm in the slightly crooked fingers ; one succeeds in straightening them only by using a certain amount of force ; the straightening of the arm meets with a slight resistance also. The patient is herself able to ac- complish only trivial movements of the fingers and arm. The right leg drags a little in walking. The sensation to touch and to pricking is very much reduced on the right side, but it seems to be somewhat impaired on the left side too ; at least, the patient makes no movement of defence. The knee-jerk on the left side is normal ; on the right side it is exaggerated, and here slight ankle-clonus also exists. In the movements of the eyes, in the pupils, and in the retina no disturbance is to be found. The pulse is rather full and hard. A closer examination of the patient is rendered the more diffi- cult as she is completely aphasic. The only words that she is able to pronounce and always repeats are " I will go to bed." It can be seen, however, that she understands simple language- 215 21 6 Lectures on Clinical Psychiatry When asked to give her hand or to show her tongue, she is gener- ally able to comply, though very slowly and with difficulty. At the same time, there is an inclination to repeat the same actions, even if afterwards we ask something else of her. She only gradu- ally accustoms herself to new instructions, and apparently does not understand complicated requests at all. She makes a faint effort, if requested, to stretch out the disabled hand, but is quite perplexed if you ask her to take hold of the right ear with the left hand. She then perhaps puts out her tongue, shuts her eyes, or makes similar mistakes. At first it is of course difficult to say whether this behaviour depends on inability to appropriately carry out properly-willed movements, and consequently on parapraxis, or upon incomplete understanding of the requests. The fact that in alternating requests the patient has at first the decided inclination to repeat the former movement, and then corrects herself, is, perhaps, in favour of the first opinion. But, on the other hand, one does not notice in the patient's certainly very limited, independent actions of the will that she has special difficulties in carrying out her intentions, or that she acts altogether in the wrong way. But, further, one sees with absolute certainty that, as a fact, the comprehension of words has suffered. If we place two different pieces of money before her, with the request that she is to take the larger or, perhaps, that of the highest value, the sense of the request remains evidently quite obscure to her. She takes first one and then the other in her hand, and lays it down again, looking interrogatively at the doctor, without knowing what is required of her. If, however, the object itself offers a certain clue for finding out our meaning, she carries it out without much delay. Thus, with a key she makes the movement of locking, opens a match-box and takes out a match, though with her one hand it gives her a good deal of trouble ; she even opens a knife with the help of her teeth. A doctor whom she happened to know formerly she greeted very heartily, nodding to him speci- ally at each visit, and understood that he was spoken of if she was asked to single him out from amongst the others. Now, too, on my asking her, she easily finds out the ward doctor, and nods to him repeatedly in a friendly manner, while she sedulously murmurs away to herself her monophrasic sentence. From these experiments we venture to conclude that the patient takes in and realizes pretty well in general the impressions offered. Dementia from Coarse Brain Lesions 217 but that she understands only imperfectly the words addressed to her. There also exists, along with the complete inability to speak, a marked degree of word-deafness. The patient presents no striking colouring in her emotional attitude ; she is in general equable, troubles very little about her surroundings, and sleeps a great deal. When taken notice of, she is friendly ; if she is neglected she weeps — as, for instance, when they had forgotten to take her into the garden with the other patients. She ex- presses neither wishes nor fear. Excitements have not been observed. Her behaviour is quite in order. She keeps herself tidy, eats of her own accord, greets the doctor, and conforms willingly to the prescribed rules. During the four months that the patient has been with us her condition has not changed substantially, but in the beginning she was not clean, had to be fed, and seemed more demented than now. This circumstance in itself would be sufficient to repudiate the suspicion of a general paralytic affection, since, when that is the case, the occurring symptoms of the central seat of disease, with very rare exceptions, usually disappear again very quickly. We are therefore forced to assume that in this case a more circumscribed damage to the cortex must have taken place in the region of the central lobe, which must have encroached on the third frontal convolution and also on the temporal lobe. As a fact, the patient has been through two apoplectic fits — the first, which was only slight, eight months ago ; the second three weeks later, being more severe. After the first attack she could still attend to her housework ; after the second almost complete palsy of the right arm and loss of speech came on. At the same time, the patient was sleepless, apprehensive, confused, and excited, wished to put an end to herself, and once even went into the river, but came out again of her own accord. Before this she had always been healthy and cheery. She had had an illegiti- mate child in her youth. Her grandmother was insane. We may find it difficult, from want of more definite knowledge, to form an absolute opinion upon the nature of the disease (under discussion) in the cortex of the brain, yet, in consideration of the repeated attacks, the sudden appearance of disturbances without symptoms of an increase of pressure in the cranial cavity, and its long unchanged duration, a vascular obstruction will first occur to us. Affections of the bloodvessels are very frequent at the advanced age of our patient ; besides, the great change of the 21 8 Lectures on Clinical Psychiatry whole mental life, especially in the excessive dulness of the patient, which would scarcely be explained by a circumscribed damage to the cortex alone, points with a certain probability to a more general participation of the cerebral cortex in the process of the disease. We might perhaps venture to think that arteriosclerotic processes in the bloodvessels of the brain have in the first place brought about general disturbances of nutrition and then local obstructions. As alcoholic and sjrphilitic injuries to the bloodvessels are recognised causes of such affections, we took these into account, though for the most part these affections usually make their appearance in the age of involution and in old age, without palpable cause. As, however, the possibility of syphilis w^as not, at all events, to be excluded, we tried to help the patient by administering iodide of potassium, unfortunately without success. The patient has, perhaps, produced now and then a single word beyond her customary sentence, or may have shown herself a little more active, but on the whole we must make up our minds that a substantial improvement of this apoplectic dementia will not take place ; on the contrary, that sooner or later the malady will make further progress through new attacks.* It is far more difficult to explain the picture presented by the strongly-built electrical artisan, aged forty-five, who now comes into the room with a rather tired and awkward gait. The patient greets us, takes a seat, and answers our questions about his personal circumstances correctly, though with some hesita- tion. We learn that he is of illegitimate birth, and was first an errand-boy and then a locksmith, but he cannot tell us any- thing about his parents or the rest of his family. At the age of eighteen he took part in a burglary, and was condemned to one year's imprisonment. " That was a real piece of scoundrel dom,'" he says ; " they should have given me a good thrashing." He married four years after this, but separated from his wife a few years later. " It was like a regular back-stairs romance, but it happened to me myself." Two of his children died in infancy. In later life he was in well-paid situations, worked hard, and felt no illness until three years ago, when he began to have severe headaches, especially in the back of his head. They came on every two or three days, sometimes by day and sometimes by night, and were quickly removed by migrainin, though this * The patient died a year later in a nursing asylum. Dementia from Coarse Brain Lesions 219 remedy, to which the patient became very much accustomed, ultimately began to lose its effect. Shortly before his admission here, where he came seven months ago, he grew sleepless, and was several times in the general hospital, but never remained there for more than a very short time. A doctor whom he con- sulted told him that there was sugar in his urine. He once slept for a whole day and night, and was weak in his legs when he awoke. Finally, he says he was brought here against his will, among the lunatics. He has fearful pains, and knows that it is all over with him. He listens to our encouraging contradic- tion of this with a melancholy smile, and says that we had better tell him the truth ; the doctors know quite well how it is with him. When we question the patient more closely about the history of his life, we are struck by the vagueness and confusion of his answers. He is very uncertain in his statements of time, and cannot remember the name of his last employer, although he worked with him for years. He can tell us hardly anything about the important events of the last few years, but says that he is a poor working-man, and has not bothered about politics. He cannot give the year or the date correctly, confuses the names of the towns where he has lived, and cannot describe what took place when he was brought to the hospital. When we ask if he has suffered from venereal disease, he says at first that he had a white chancre twenty years ago, but afterwards dates it three years before his admission to the hospital, and also mentions two attacks of gonorrhoea. He does simple sums correctly, but gives them up altogether when he has to carry a figure in his memory. He has a certain consciousness of this severe disturbance of his memory and power of attention, and says it is ridiculous that a man of his age should not know better where he is. The patient's mood is, as a whole, depressed and hopeless. Although he has no clear idea of the severity of his illness, and tries in part to account for its symptoms by external circum- stances, he feels his helplessness very strongly. He reproaches himself with having practised onanism in his youth, with his imprisonment, and with the loss of his place, and fears that ill results will follow his leaving off the migrainin powders, yet says that he could not take them any longer. On the other hand, it is easy to divert his mind, if only for a moment, and even to make him laugh. The weakness of his will is very marked. 2 20 Lectures on Clinical Psychiatry as is evidenced by his excessive docility. He does everything he is told to do, declares at once that he is willing to stay in the hospital, although he complains of being " kept a prisoner," and has no definite plans or wishes for the future. You will have noticed during our conversation with the patient that he expresses himself slowly and clumsily, is often obliged to search for the right words, and makes mistakes, such as " position of honour " for " position in life." He is particularly apt to repeat words or syllables that he has used a little while before in the place of those he washes to use now, a disturbance which points to the persistence of previous motor impulses. All these symptoms gradually become more and more pronounced, evi- dently as the result of fatigue, until at last it is difficult to under- stand him. When he tries to write, corresponding symptoms are very plainly seen. The patient begins by writing his name with ease, but after a few words he ends with a quite incomprehensible scrawl, in which only one or two letters can be made out, and that with difficulty, while their arrangement in syllables is wholly frustrated by inversions and mistaken interpolations, and more especially by the unmeaning repetition of the same strokes. Finally, he lays down the pencil in despair. The patient is strongly built and well nourished. His physical examination shows that the reaction of the pupils is maintained, but that there is slight nystagmus on looking to the right, with perhaps some indications of right-sided hemianopia, so far as his mental awkwardness allows us to form an opinion. Cutaneous sensibility is somewhat reduced on the right side, and the patient recognises objects placed in his hand, better with his left hand than with his right. There are no marked palsies, but the gross strength is considerably reduced, particularly on the right side. All the patient's movements are slow and awkward, and he cannot imitate simple positions of the hands. His gait is unsteady and groping ; he sways when his eyes are closed, and his outspread fingers show fine tremors. The knee-jerks are active and equal on both sides, and there are no further dis- turbances to be discovered, as far as the nervous system is con- cerned. The temporal arteries are much corrugated, and stand out visibly, and the radial arteries are fairly hard. The pulse is full and regular — 72 — and there is nothing abnormal about the heart. There is marked albuminuria. The combination of mental weakness, especially loss of memory, Dementia from Coarse Brain Lesions 221 with signs of a severe affection of the brain, might lead us to think in the first place of general paralysis. This suspicion is strengthened when we learn that the patient had an attack of syncope two months after his admission, followed during the next few days by the development of marked aphasia, with hemi- anopia, anaesthesia, and paresis of the right half of the body. At times he was quite stupefied, and he had several attacks of vomiting. All these disturbances cleared up speedily, if not quite completely. A month later there was transitory retention of urine, and six weeks after that the patient had an epileptiform attack. These disturbances might easily be supposed to be paralytic seizures, yet we cannot help noticing that certain peculiarities of the case do not altogether agree with the usual picture of paralysis. On the mental side there are the complete absence of delusions, the consciousness of illness, which is, com- paratively speaking, very good, and the patient's perfectly orderly and sensible behaviour. We must also remark that the disturbance of speech and writing does not present the atactic and paretic features of general paralysis so much as paraphasia, paragraphia, and recurring utterance. Again, the great liability to fatigue, which is so plainly marked here, is not observed in the same way in paralysis. Under these circumstances, we will have to ask ourselves if some other interpretation of the picture of disease is not possible. In the first place we might think of a syphilitic, and in the second of an arterio-sclerotic affection of the brain. The patient's statements make it seem doubtful if there has really been syphilis, but in consideration of the bad outlook of the case, we felt we ought to make the experiment of beginning a mer- curial cure. As the patient's condition quickly grew worse, and the quantity of urine diminished, while the albumen found in it increased, we were soon obliged to give up this treatment and confine ourselves to administering iodide of sodium, with the result that the dangerous symptoms described disappeared, but that practically no change occurred in the patient's general condition. After this experience, the idea of a syphilitic foundation for the malady, although it cannot be excluded, has certainly found no confirmation, and the possibility of an arterio-sclerotic change is therefore increased. The presence of albumin in the urine and the visible arterial changes are in favour of this theory, 22 2 Lectures on Clinical Psychiatry while the fact that the patient is comparatively young is opposed to it. The nature of the focal symptoms, especially their rapid development and their fluctuations, are more suggestive of arterio-sclerosis, and the absence of inactivity to light in the pupils might also be taken in this sense. Finally, it should be noticed that simple feeble - mindedness, without delusions or hallucinations, is comparatively common in arterio-sclerosis. We therefore come to the conclusion that we have not to deal with general paralysis, or with a syphilitic affection of the brain, but with arterio-sclerosis of the vessels of the brain. Why this disease has attacked our patient at a comparatively early age must be left undecided, especially as our knowledge of the causes of arterio-sclerosis is anything but clear or satisfactory at present. The prognosis is extremely bad, and the illness may be expected to progress continuously, and to lead in a few years to the appear- ance of many focal symptoms of various kinds, and to death.* We are encouraged to continue the discussion thtis begun by the case of the plasterer, aged fifty-two, who now comes limping awkwardly into the room with an untidy nosegay in his button- hole. The patient greets us with lively garrulity, and makes relevant and generally correct replies to the questions asked him, but always goes off into an almost incoherent flood of words, which very soon takes the form of a description of his experi- ences in the war, and a request that he may be sent to the Government baths at Baden-Baden for his rheumatism. He is easily divertible, but only follows up fresh suggestions for a moment, returning at once to his former request, which he makes again and again at great length in almost the same words. He makes a quite senseless use of extraordinary interjections in his noisy talk, such as " fasso," " fasso soso," and " fasso t'other way round," formed from the French word fa^on. We discover in the course of our questions that he is perfectly clear about relations of time, and knows quite well where he is and who people are. He says he has come from the penal work- * Unfortunately, at the time when we examined the patient we did not yet know of the important assistance afforded by cytodiagnosis. The presence or absence of an increase of lymphocj^tes in the cerebro-spinal fluid would have been of great importance in distinguishing between syphilitic and arteriosclerotic disease. The patient succumbed in a nursing asylum fifteen months after his admission to our hospital. On post-mortem examination of the brain undoubted arteriosclerosis was found. Dementia from Coarse Brain Lesions 223 house, where he was " betelephoned." The overseers did that, and now he is here he still hears telephone voices from there. " So now, that about the telephone, that is like this ; there is my bed and there is the wall that's electric. There I have my pains in the back and shoulder ; that comes of being electrified. There, in the door, there is a handle ; they fix that, and there it jolts and electrifies. That comes of my having slept on the plank bed in the workhouse ; from the shaking, I have the thing in my head and my ears, and in my shoulder it feels as if I were frozen hard. They hear and repeat everything that we think ; I hear every word what they say there, and they hear what I say." When asked what the voices are talking about, he listens attentively, and says : " Now they are just saying Now they are not talking ; they say Now they are ready. — Now one mustn't say anything more. — The doctors say that. — Now they are jawing about politics, says mother." " It is just as if we were talking to one another here." He goes on to tell a confused story about a magical prophecy a postman made to him. " He said the German Emperor was shot, the Grand Duke was shot, and I came into the room as a target. Then I had the Russian Emperor telegraphed to, as an infantry soldier, to get him buried ; he came and spoke to me ; he is called Frederick Czar. I wished to marry the Princess Maria Theresia Hildazar. I won't be contradicted about it, that the overseer and the post- man, that they that about the ambulance story and the magic story ; but they have been shot with the electric shooting machine." In the further course of the story, which is accompanied by a great deal of gesticulation, the patient asks for his uniform as King Halleluja of Portugal, which he thinks is here now. He also demands his pension of 800 marks, and asks for leave of absence to go and marry the Princess Carolina Victoria at Berlin, and drive away from the pine forest as a general, at first, until he is crowned. He appoints the doctors surgeon-majors, and is going to take some of the patients with him and give them various posts. At Baden-Baden he intends, as German Emperor of Russia and France, to summon an Imperial Congress at which all the German Princes and great families are to be present. The patient's mood is exalted and easily excitable. He often bursts into unrestrained laughter, but says : " I can't help laugh- ing. I don't want to laugh, but I can't help it ; it comes and 2 24 Lectures on Clinical Psychiatry goes : it is just like the sea." He adopts the tone of a good- natured colleague towards us, claps us on the back and bangs hard on the table, to emphasize his words. His behaviour is rather boorish, but natural and orderly, and we only notice a certain restlessness and loquacity in him. The physical examination of this tall and very strongly-built man shows in the first place, as the explanation of his limping, old-standing disease of the right hip-joint, with backward dis- location and shortening of the leg to the extent of 7 centi- metres. The left arm is rather weaker than the right, and the patient says that he often has a feeling of formication in it, but a disturbance of sensation can hardly be made out. The left side of the face seems rather more flabby than the right, and the knee-jerk is stronger on the left side than on the right. The reaction of the pupils is normal, the patient's speech is rather indistinct and slurred, and his writing shows little irregularities and bends. He often leaves out letters, but it is difficult to estimate the importance of this, on account of his very defective orthography. The radial arteries are much corrugated and very hard, and the pulse is tense and slow. These are all the abnormalities to be noticed on the physical side. With regard to our patient's previous history, we learn that he fell ill during the campaign of 1870-1871, and was taken prisoner by the French. His hip-joint suppurated, which led to the shortening of his right leg. From the year 1881 onwards he fell into drinking habits, and gradually sank lower and lower. He was convicted some sixty times of begging, disorderly con- duct, disturbance of domestic peace and grossly offensive behaviour, and a few times of assault and petty theft. He M^as also committed three times to the penal workhouse, the police surgeon having repeatedly declared that he was not insane, but only a degraded drunkard and malingerer. In the workhouse he was remarkable for his insubordination, which no disciplinary measures could check. As he finally grew threatening, refused to eat, and talked about a visit he was expecting from the Emperor, he was transferred to our hospital seven months ago. Here at first there was not much that was remarkable about him, except his long-winded and monotonous loquacity. He wrote a quantity of letters and petitions to every conceivable person of high social or official position, setting forth, in a rather confused way, his services in the war, and his claim to nursing Dementia from Coarse Brain Lesions 225 and medical treatment at the Government baths. He was in a perpetual state of noisy merriment, made clumsy jokes, harangued his fellow-patients, lilled his pockets with all sorts of rubbish, decorated himself with cigar-bands and leaves, and tied threads round his fingers. From time to time he gave expression to fantastic and frequently-changing delusions, similar to those you have heard of to-day, saying that he was descended from a Russian general and his wife from a French one, that he ought to be German Emperor and Crown Prince, and a general field - marshal on the retired list, and that these were telephone stories. These statements were generally made in a joking way, and were readily influenced by persuasion. His behaviour at that time was orderly on the whole, and he often helped in the work of the wards. About five weeks after his admission he suddenly had a long series of severe convulsive seizures, occurring as often as eighty times in the twenty-four hours, and extending over seventeen days. The attacks invariably began with rolling of the eyes upwards to the left, turning of the head to the left, and clonic convulsions of the left arm and leg and the right arm. Then followed violent twitching of the arms and face, especially on the left side, with rigid extension of both legs, shaking of the whole body, spasm of the maxillary muscles, and interruption of the breathing. The convulsion subsided in the space of one minute, and the pupils, which had been much dilated and immobile, reacted again. After a short time of delirious stupe- faction, the patient quickly came to himself, recognised his sur- roundings, and showed that he imderstood the measures taken by the doctor for his relief, but refused to believe that he had had convulsions. As the illness progressed, he was often stupe- fied and confused, even between the attacks, but generally in a happy frame of mind. When the attacks gradually disappeared, spastic disablement of the left side was observed, with anaesthesia, exaggeration of the knee-jerks, and Babin ski's reflex of the long extensor of the foot. The fundus of both eyes was normal, the pulse was persistently hard and tense, slow at first, and after- wards accelerated and often intermittent. All these disturb- ances soon disappeared, leaving but slight traces. Since then the patient has shown decided mental deterioration, the hallu- cinations of hearing and extravagant delusions having grown more marked, while speech and writing have become worse. 15 226 Lectures on Clinical Psychiatry This case might be taken at first for one of general paralysis. The senseless and readily - influenced ideas of grandeur, the attacks which remind one of paralytic seizures, and, lastly, the disturbance of speech and writing, all seem to favour this view ; but there are also important considerations opposed to it. The patient was always perfectly clear about time and place, and never showed the characteristic amnesia of general paralysis. Even now, in spite of his obvious dementia, he shows a mental activity and a liveliness, which is not generally found in that disease. The strong predominance of hallucinations of hearing, too, is very unusual in general paralysis, except in the tabic form. Moreover, there was absolutely nothing abnormal in the pupils, the disturbance of speech and writing was very slight,, and the attacks themselves were different from those of par- alysis. The quick return of collected consciousness, which in- variably took place between the individual attacks, was specially remarkable ; in a long series of paralytic attacks patients gener- ally remain permanently and deeply stupefied. Again, the convulsions most plainly showed the features of a circumscribed lesion of the cortex ; after they had passed off, traces of the disablement suffered remained for many months, and this is always unusual in general paralysis. Under these circumstances, we shall have to ask if some other interpretation of the case is not more probable. The behaviour of the pulse might seem to suggest an arterio-sclerotic affection of the brain, but here again we meet with difficulties. The comparatively slight impairment of memory, in conjunction with the well-marked delusions, and more especially the hallu- cinations, do not suit the description of that disease ; neitherdoes the slight disturbance of speech, which is more like slight paresis and ataxy, agree with the assumption ; nor, indeed, does the long series of convulsive attacks, with their comparatively insignifi- cant after-effects. On the other hand, the same signs which have been obstacles to the interpretations we have discussed, point to yet another possibility — that of a cortical lesion of syphilitic origin. The unimportance of the disturbance of memory, the retention of mental clearness and activity in spite of marked feeble-minded- ness, the permanent hallucinations of hearing, the changes in speech and writing recalling paralysis, but much slighter, and the convulsions, which are indicative of a circumscribed lesion,, Dementia from Coarse Brain Lesions 227 are signs which undoubtedly can best be interpreted by the assumption of syphilitic changes in the arteries. The cause of this disease is very much slower than that of general paralysis or arterio-sclerosis, and a simple condition of more or less pro- nounced dementia, with isolated physical disturbances, may develop, which will continue without change for years, often with persistent hallucinations of hearing.* As a rule, anti- luetic treatment has little effect on this condition. * The patient succumbecf two months later to a fresh series of severe attacks. An apoplectic lesion was found at the base of the right prefrontal region, together with contracted kidney, enlarged heart, degeneration of the muscles of the heart, and disease of the arch of the aorta. Unfortu- nately, it was not yet possible at that time to make use of lumbar puncture, which would at least have enabled us to exclude the theory of simple arterio-sclerosis. IS— 2 LECTURE XXIII SENILE DEMENTIA Gentlemen, — At the very beginning of this course of lectures you learned that melancholia was a disease of which the appear- ance seemed to be connected with the general failure of strength and vitality in old age. There are also a number of other mental disturbances, which appear most frequently in the years of reversion, a time when the power of resistance is reduced. The various forms of maniacal-depressive insanity are among the most common of these, and so also is paralysis, especially in women. Less common are epilepsy, and those forms of insanity which are not connected with any particular time of life, such as poisoning and toxic infection of all kinds, whether acute or chronic. Finally, there is a rather large group of disturbances which bear the stamp of the mental decline characteristic of old age even more distinctly than melancholia. One of these forms has already been fully discussed in the senile delusion of persecution. Another closely-associated form is presented by an india- rubber worker, aged eighty-six, who comes into the room slightly stooping and with shuffling steps. He replys to our greeting in a friendly way, with a familiar wave of his hand, and proves to be both accessible and talkative. He tells his age correctly, but makes a mistake of several months in giving the actual date, and supposes that the conversation is taking place in the year 1991, though he corrects himself when we remonstrate with him. He does not know how long he has been here, " a year or six months perhaps," but he knows quite clearly that he is in a hospital, " for his head." He knows the doctors " by sight," but not their names, and says that he has seen the assistants before. He can tell us nothing about his 228 Senile Dementia 229 illness, and does not know how it began or how he came here. When we remind him that, eight months ago, he suddenly washed himself with urine and drank his own urine, and that he could not help running three times to the railway-station and coming back a particular way, he remembers what took place, but cannot give any account of his reason for doing it. " That I don't know," he says; " that I don't know even now." When we tell him that he declared he was Jesus Christ, and had been in heaven, he laughs heartily at firot, and asks, " Did I really say that ?" Then he grows serious, and says : " Yes ; but I knew that my wife has turned off the water, so that I can't be drowned." He answers all our questions, though not very fully, about the occurrences of his earlier life and political events until thirty years ago, but can tell us hardly anything about what has happened since. He has retained what he learned at school, and particularly his arithmetic, fairly well, but he forgets words and figures, to which he has been told to give special attention, within a few minutes, and has no idea of what he has said or done in the last few days, or even the last few hours, listens half incredulously when we tell him of it, and repeats the same stories several times, without noticing that he has told them already in the same conversation. His mood is childishly merry, but sometimes, when he is contradicted, he is peevish and irritable. He wishes to go home, but says that he is quite con- tented when told that he is still ill, and hopes to be well again soon. He says he has it in his head at times ; his daughter-in- law, the slut, ran her finger over his teeth and made him crazy. The principal result of the physical examination is the discovery of signs of advanced old age : atrophy of the skin, joints and muscles, extensive arterio-sclerosis, and indications of cataract. The left pupil is larger than the right, and the reaction to light is unsatisfactory in both eyes. The patient is rather deaf in the right ear. The clinical interpretation of this condition would give but little trouble, even if the patient's age did not set us on the right track at once. The confusion about time and surroundings, associated with well-maintained power of comprehension and mental activity, the wild delusions associated with a certain sense of illness, the patient's want of understanding of the general situation and his vacuous cheerfulness, but, above all, the profound failure of attention to present impressions and 230 Lectures on Clinical Psychiatry the very extensive loss of memory, which has only spared the inveterate impressions of a time long past, complete the picture of that morbid exaggeration of the changes seen in normal senility, which is known as senile dementia. It is true that a high degree of disturbance of the attention is met with in general paralysis and in Korssakow' s disease also, but in the former affection, even if we disregard the physical signs, so severe a disturbance of the attention to impressions is almost invariably associated with marked dementia, dulness, loss of compre- hension, mental clumsiness, and poverty of thought, while the loss of memory includes the impressions of early life, and attacks the arithmetical faculty, as well as the sense of time, at a very early stage. The distinction from Korssakow's disease is more difficult, if the patient's age and history are not considered, yet the failure of attention is greater there and the loss of memory less than in senile dementia. The judgment, too, is much less clouded, the delusions, when they are present at all, are not so senseless and confused by far, and the mood, in place of the childish cheerfulness of senile dementia, shows more of the dull or humorous placidity of the drunkard. With regard to the patient's former history, I must now tell you that he belongs to a healthy family, has three healthy children, and has never been addicted to drink. He worked until eighteen months ago, but even then he had been complaining for some time of violent headaches. He used to get up in the night, put wet cloths on his head, grumbled to himself, wandered about the house, looked for his clothes, thought his things were lost, and knew nothing next day about this restlessness at night, which is highly characteristic of senile dementia. About eight months ago he began the strange behaviour already described, and said that he was a disciple of Christ, and had got a gold medallion. He was sometimes irritable, and scolded his daughter-in-law, telling her that she was a great sinner, and would go to hell. When he was admitted here, seven months ago, he called himself the Son of God, and said that he had often been in heaven, and had driven there through the air the night before in the golden carriage. When asked what it was like, he said that it was just like what it is on earth, only the fruit was better, and people only ate half as much, so they got a better living. Everything was finer there. There were no bad people in heaven, and no railways ; people had to work hard, Senile Dementia 231 and not to idle. His wife had been in heaven for twelve years ; he had redeemed her the night before. The Holy Ghost had commanded him to do good and rebuild Mannheim. " All the rich people who have gobbled up the money must help to build, with Rothschild at their head." He was quite confused about time, and did not know where he was. He slept little at night, whispering to himself and beating his breast. His mood was generally contented, but sometimes he grew peevish, and scolded at the warders, " who eat everything themselves, and leave us nothing over." Once or twice he was gloomy and unsociable, and would not speak, but lay with his eyes shut, and resisted violently when he was interfered with. He explained afterwards, when he had suddenly become friendly and accessible again, that the Holy Ghost had been with him. He occasionally refused his food, saying that he was fed by the Holy Ghost, and did not need to eat anything. Gradually the patient became a little more clear about his position, and even said that he was quite crazy, but changeable delusions kept reappearing now and then ; for instance, that his wife had risen from the dead, and brought him two orders of merit, that he was President, and the like. He sometimes made long speeches to his fellow-patients about what he had seen and done in heaven, with more or less fantastical descrip- tions, which he forgot completely afterwards. Once he had a brief attack of giddiness.* The development of the symptoms described here is in full agreement with common experience, and the alternation of the condition between delirious and lucid periods is especially common. The only unusual feature is, perhaps, the somewhat rapid development of the illness, but it may be assumed that slighter disturbances, such as occur in normal senility, had been present for some time. The most obvious cause of such disturbances is to be found in the senile lesions of the blood- vessels, but there is no doubt that, independently of these changes, a large area of nervous cortical tissue atrophies, at any rate in morbid senile dementia. You may learn the characteristics of senile dementia very clearly from the case of a woman, aged seventy- two, who was brought here six months ago. She had always been mentally and * The patient is still living, two and a quarter years later, and is in a nursing asylum. 232 Lectures on Clinical Psychiatry physically healthy, married at the age of thirty, and had four children, of whom two are still living. We could learn nothing of any heredity. This woman has had a great deal of trouble ever since her husband's death, which occurred seven and a half years after her marriage. But it was only about a year ago that a great change took place in her, although she had complained of headaches and giddiness for some years. The patient gradually became forgetful, was confused as to time, and did not even know her way about her house, could not remember whether she had had her meals or not, and mistook people. She thought her daughter was her sister, and often spoke of her parents, long since dead, as if they were still alive. She also showed a certain degree of restlessness. The patient became irritable, peevish, and distrustful, would not go to bed in the evening, and got up early before dawn. She rummaged about aimlessly, wanted to go out, could no longer do her work in an orderly way, and had a capricious appetite. The patient is small and bent, with wrinkled features and white though still fairly abundant hair. Her state of nutrition is below par, but otherwise, apart from trembling in her hands and irregular action of the heart, she shows no very striking physical defect. She understands the questions put to her correctly, though often with some difficulty, and only after they have been repeated. It appears from her answers, however, that she is quite vague about time, place, and surroundings. She thinks she is here at a wedding, and imagines she knows all the people in the place, though she cannot tell their names. She complains herself of having become so forgetful — " I cannot get hold of things." She feels so much alone, and has not troubled about things. She sometimes gives the year of her birth, and sometimes some other figure, as the date of the present year, says alternately that she is thirty or sixty or less than twenty years old, and is very much amazed at being addressed as " Old lady." She is quite unconscious of the grossest contradictions in her statements of time. Thus she asserts that her daughter is two years younger than she, that her father is sixty, when she has just given her own age as sixty, that her child is three years old, and so on. She says that she is living with her parents and grandparents, and calls herself by her maiden name. The Grand Duke's name is Leopold, and the coins she is shown are gulden and kreutzers. Senile Dementia 233 After a little persuasion she quite agrees that she is going to be married soon, and says that a man from the neighbourhood comes to look out for her every day. In other matters, too, she is easily persuaded of anything whatever, and assents when she is told that she had a visitor yesterday, and went for a walk. She spins out such suggestions at greater length herself, and knows who it was that came and what he brought her, and where she went for her walk. But it is very remarkable that, in spite of her accessibility to persuasion, she cannot be led into senseless statements on any other subject than the order of events in time. If you say to her that snow is black, she answers, " Yes, certainly, when soot falls on it." Blood is not black, " but yet dark." Cherries are green " at first, but afterwards they turn red." She understands these contradictions quite well, and often shows a sense of humour. To the question if a thief is not an honest man, she replies, with a laugh, " Yes, but we won't go into that "; and when I tell her she has stolen herself, she answers readily, " I don't usually, but I would have my stupid cough stolen at once." The rapidity with which the ideas aroused fade again is exceptionally striking in our patient. She forgets everything that happens in a few minutes, and often almost in a moment. She complains to the doctor, immediately after he has given her an injection, that a girl has been there and pricked her. Pure inventions take the place of the real events. Once, when the patient had tied a cloth round her foot, she said in close succes- sion, first that her shoe had come off, and that she had been obhged to tie it on again, then that she had made herself a bandage because a piece of wood had flown against her foot, and, lastly, that the doctor had hit her on the foot, and so she had been obliged to tie it up. When experiments were made of showing her pictures and objects, more than a quarter of the impressions were forgotten after only five seconds, while after thirty seconds only a quarter remained, and later none at all; That the patient herself noticed the fleeting character of her ideas is evident from her remark, " I don't know ; one cannot hold things any longer in one's whole inside." The patient's mood is indifferent on the whole, but occasion- ally peevish, though often merry, with a tendency to joke. She frequently shows a certain degree of unrest, packs up her belongings, and wants to go away to her parents or to the wedding, 2 34 Lectures on Clinical Psychiatry declares that she has a child in her quilt that must be christened, and is rude when anyone tries to put her to bed again. Her sleep is very much affected by the restlessness, but she takes a sufficient quantity of food, and keeps herself clean with a little help. The most prominent feature of the case is evidently the almost complete failure of the power to retain impressions, which far exceeds anything we have observed in other forms of disease. The single ideas aroused by subjective and objective occurrences fade again so quickly that absolutely no connected chain of ideas ever comes into existence. Besides this, there are many indi- cations that clear impressions are far more slowly arrived at than is the case with healthy people. Hence many of our patient's ideas vanish before they have ever really become clear. It is easy to understand, to a certain extent, how the united effect of these two disturbances may produce the condition presented by her, which we will call " presbyophrenia." The great prominence of this inability to retain impressions in the more severe forms of the insanity of old age seems to me to justify the view that those states of depression and excite- ment in which it is a leading feature, and so increases the proba- bility of an unfavourable prognosis, are also to be considered as varieties of senile insanity.* If further experience shows that this view is correct, we may perhaps have found a criterion for the distinction of melancholia, as we have previously defined it, from real senile dementia. We must, however, recognise that the interpretation of those cases of disease which occur at the beginning of old age is often very difficult. Before you sits a woman, aged sixty, in whose case a whole series of diagnoses might be entertained. This woman is said to belong to a healthy family, and to have been well herself until a year or two ago. In the last few years she was avaricious and suspicious, afraid she would be robbed, and took unusual precautions against what she thought were bad neighbours. A few weeks before her admission, which took place six months ago, she became quieter, and grew very apprehensive, prayed, and got out of the window at night, and went to a neighbour, begging to be allowed to stay with him. Next night she climbed right on to the roof, and was taken * The patient died three years later in a nursing asylum, after having gradually grown duller. Senile Dementia 235 in through a dormer window, resisting violently. She showed great apprehension, and wanted to hand over her money to her neighbours, because she thought that the devil was in it. Some- times she talked quite rationally, and remembered everything that had happened. On her admission the patient was mute, sat straight up in bed, absolutely refusing to be put into any other position, and resisted every effort to influence her. Next day, however, she carried out simple orders, showed well-defined catalepsy, took up the attitude of a preacher, standing on her bed with her arms raised on high, and would not answer any questions, only saying twice shortly, " Go away." She took no food, and refused to urinate, so that the catheter had to be used. After- wards she stripped herself naked, and crouched in that condition on the floor, or lay down under the bed. It was not till a week later that she suddenly began to talk, and apologized for the trouble she had given, saying that she had not been hungry, and could not eat. She was quite clear about her surroundings and her late experiences, and had a vague feeling of illness, but did not really understand how senseless her actions had been. Next morning she was cataleptic again. She was dumb and obstinate as before, and sat without moving, holding out her thin twist of hair horizontally in her right hand. She showed frequent changes of behaviour in the period which followed. Sometimes there was lively apprehension, and she also seemed to hear voices, for she would look at the ceiling with the question : " What do you want ? I am coming immediately." At other times she was more accessible, was pleasant, smiled, and talked quickly and almost incomprehensibly in a low voice. It is in this condition that you see her now. She sits there, almost entirely apathetic, and does not trouble about what takes place around her. She answers emphasized questions, however, and gives her name, knows where she is, and knows the doctors, but not their names, nor can she name any of her fellow-patients or the nurses. She is confused about time, and makes quite incorrect statements, excusing herself by saying that she has not been able to look at a calendar. She cannot even tell us the year or day of her birth. Her school knowledge, too, is extremely scanty, so far as it is possible to find out anything about it from her. She has no correct idea of her position, and does not worry about the future or ask to be allowed to go home. 236 Lectures on Clinical Psychiatry Her mood is indifferent. She often gets into a frightened and tearful condition, but is easily persuaded out of it, and grows cheerful and loquacious, but foolish. She says her head is " good and healthy." Apart from slight trembling of the hands, no physical disturbance worth mentioning can be discovered in this feeble and scantily-nourished woman, who often has to be fed artificially. We can hardly doubt that, at the present time, the patient presents a marked degree of dementia and incapacity to work out external impressions clearly, with poverty of thought, weakness of judgment, loss of knowledge formerly possessed, and emotional dulness. It is true that she has several times shown great excitement on her husband's visits, but on all other occasions the want of deep emotion and the feeble-minded changes of mood are distinct enough. We can hardly take the con- dition for melancholia, which has passed into mental enfeeblement, as the characteristic depression has been absent from the whole course of the disease, nor has there been the delusion of sin which is usually so prominent in melancholia. The desire for sympathy, which makes melancholic patients so fond of giving an impres- sive account of their dismal ideas to those around them, has also been entirely absent. In place of all this we are met by a number of symptoms which we have seen already in katatonic illnesses — dumbness, negativism, catalepsy, extraordinary atti- tudes and actions, abrupt alternations of stupor and accessibility without consciousness of illness, and, finally, hallucinations. If, in spite of this, we hesitate to suggest katatonia at once, it is because we almost always see that disease appear at a much earlier age, and there are certain features in the history of the case which are characteristic of senile dementia — namely, suspicion, defective ideas of time, and rapid loss of former knowledge. It is true that the power of retaining impressions does not seem to be affected to the same extent as it was in the last patient, but it was impossible to make an accurate exami- nation on the subject on account of the patient's obstinate and apathetic behaviour. It should, however, be pointed out that the establishment of single katatonic features does not in itself justify the diagnosis of katatonia, as such s>Tnptoms are often seen elsewhere — in general paralysis, for instance. It is, therefore, possible that we may sometimes have to accept as forms of senile dementia Senile Dementia 237 cases which exhibit katatonic symptoms, but are not to be con- fused with the real katatonia of earlier life. At present we are not in a position to answer the question as to the clinical position of this group of cases with certainty, but perhaps it will be pos- sible to do so some day with the help of pathological anatomy. We may be satisfied to-day with having pointed out the peculiar katatonic forms of disease in old age. As far as I can see from my own experience, the prognosis is very unfavourable in these cases. They lead to considerable and often to profound de- mentia, in which indications at least of the katatonic symptoms generally remain to the end.* * The patient died after two years spent in a nursing asylum, demented, dull, and negativistic. LECTURE XXIV EPILEPTIC FEEBLE-MINDEDNESS Gentlemen, — We have already met with more or less obvious periodicity in the phenomena of disease on various occasions. We have learned to recognise large groups of varieties of insanity, which run their whole course in a series of sharply-defined and sometimes quite regularly recurring attacks. The cause of this periodicity must of course be sought for in permanent changes in mental life, on which we are generally quite unable to put our finger in the intervals. We are in just the same position here as we are in regard to the many periodically recurring phenomena in the healthy body — pulse, breathing, sleep, menstruation, etc. — in which we cannot as yet give any clear reason for the periodicity, although we recognise it. But in the province of disease there is no lack of examples where, side by side with the periodical discharge, a permanent change in the personality is plainly seen, showing that, in reality, the individual outbreaks are not in- dependent illnesses, but only the expression of a fundamental morbid condition. The final stages of dementia praecox, with their very frequent periodical excitement, have already afforded instructive examples of this. To-day we shall have to consider another group of morbid conditions, often very similar outwardly, but essentially of quite a different kind, in which very transitory mental disturbances also recur, more or less regularly, side by side with permanent feeble-mindedness. I will first show you a journe^Tnan joiner, aged eighteen, who has already been in the hospital five times in one year. He is said to belong to a healthy family, but to have lost two brothers or sisters at an early age from convulsions. He had an attack of convulsions himself when six months old, which recurred about every three months at first, and afterwards every month. Often 238 Epileptic Feeble-Mindedness 239 the attacks came in paroxysms by night as well as by day. Two years and six months ago, and again eighteen months ago, the convulsions were accompanied by bewilderment, apprehension, and hallucinations. It was in this condition that the patient was brought to the hospital for the first time a year ago. After six attacks had occurred in the course of four days, the patient, who until then had been quiet and monosyllabic, became restless and apprehensive. He thought he was going to die, became sleepless, prayed, was anxious to get out, and said that some journeymen shoemakers living in the neighbourhood had stabbed out his eyes with long knives, and put in beast's eyes instead, and had cut out his gullet. He had heard his master say that he was not much longer for this world. He was also confused, forgetful, and giddy in his head. This condition lasted about a week. Attacks of this kind recurred several times, and generally led to the patient's being brought to the hospital. Here, too, they were often observed, and usually followed a series of convulsive seizures distributed over several consecutive days. The patient then became confused and excited, and expressed hypochon- driacal ideas. He said that he was dead, had no blood left, or could not clench his fist, or complained that his eyes were growing so large. Then he thought that attempts were made on his life, and that " they " wanted to shoot him. He saw men aim their weapons at him, became very much irritated, called for help, and ran about apprehensively. Af ler a few hours, or sometimes days, he grew quieter. He still held fast to his delusions at first, but at last admitted that he had been " delirious " again. His weight, which had fallen considerably during the attack, began to increase again rapidly. In the intervals between these attacks, which used to recur about every three or four months, the patient had frequent, but slight, attacks of convulsions, in which he lost consciousness, and showed tonic and clonic twitchings for a few minutes at a time. Attacks were also observed in which he lay quite flaccid, with his eyes closed, and paid no attention when he was called or pricked with a needle, but shut his eyes tightly if anyone tried to open them. The pupils were dilated, but contracted on exposure to light, and there was transient catalepsy. The knee- jerks could not be excited on account of severe spasm. The pulse was accelerated. This condition disappeared in a few hours. 240 Lectures on Clinical Psychiatry Lastly, the patient himself complained of quickly passing attacks of giddiness, with trembling and weakness in his hands, " as if an attack were coming." On these occasions he did not lose consciousness completely, and soon recovered. The slightly-built, pale-looking patient has a small forehead, and the root of his nose is depressed. His ear-lobes are soldered, and his palate is high-arched. All these abnormalities are gener- ally regarded as signs of degeneration. The pupils are dilated, but react well. The outspread fingers tremble, and the skin- reflexes are very active. The considerable decrease of sensibility to pain in the whole body is very striking. You can stick needles through folds of skin anywhere, without the patient's showing pain, but his sense of touch does not seem to be diminished. Physically, you will remark, above all, the patient's great clumsi- ness. He is collected and clear about place, time, and surround- ings, but answers questions very slowly and after long delibera- tion. He does not always understand what is required of him at once, in spite of his perfect attention, and cannot get forward with his explanations. He admits that he is ill, but is unable to tell us much about it. He says that the last attacks were quite slight. He has only a very faint recollection of the state of bewilderment. The warders had revolvers to shoot him ; he was in heaven and saw God ; he saw everything he thought of plainly before him. His head is often giddy, so that he cannot think clearly. Although he did not do badly at school, his knowledge is very scanty. He has absolutely no idea of things and their relations lying outside his immediate daily horizon. His stock of ideas and his judgment are about on a level of those of a child ten or twelve years old. He is indifferent to his fellow-patients and to what occurs around him, so far as it does not touch him per- sonally, but he shows great attachment to his family, and speaks of his dear father, to whom he would like to return. He is also very much pleased at being visited. Apart from the attacks, his behaviour in general is quite orderly. He is certainly rather dull, but he is good-tempered and manageable. It is only when the attacks are coming on that he grows irritated and threatening. He does not occupy himself much, but carries out simple work entrusted to him carefully, though extremely slowly. Con- sidering his marked feeble-mindedness, some sketches he has copied from coloured pictures of animals and plants are very Epileptic Feeble-Mi ndedness 241 remarkable. Every stroke of the very naturally executed pictures is reproduced with such care and accuracy that it is almost impossible to distinguish the copy from the original. But when we set the patient the task of constructing simple •diagrams from figures given him, he proves quite incapable of executing the work, which demands a certain amount of ■originality, but is in other respects very simple. That our patient is suffering from epilepsy is proved by the convulsive seizures, which go back to his earliest childhood, recur at fairly regular intervals, and have gradually grown more frequent. He has also had slighter attacks of giddiness, and in the last few years states of semi-consciousness, fully correspond- ing to the recognised description of epilepsy. His states of languid stupefaction are less usual, and without consideration of the whole picture, might easily have been regarded as hysterical. The analgesis also would apparently have fitted well with this interpretation, but it did not show the limitation to any particular region so common in hysteria. Finally, our patient has, in the course of the last year, developed a peculiar progressive feeble-mindedness, differing essentially from the last stages of uncured mental disturbances hitherto considered by us. It is specially characterized by mental clumsiness and awkwardness, with complete maintenance of collectedness and proper order of thought, apart from the attacks. There is also .an extraordinary narrowing of the intellectual horizon, within which, however, the patient finds himself tolerably at home. This is the opposite of the last stages of dementia praecox, in which considerable fragments of higher education can often be ■seen, while capacity for the simplest mental operations seems to be annihilated. The deficiency of memory has led to a profound impoverishment of our patient's stock of ideas. But, contrary to what is the case in general paralysis, the more remote and general ideas have been lost first, while what has lately occurred and is of immediate importance is still very well retained. Our patient's emotional relations, too, are not universally dulled, as they are in dementia praecox, but only circumscribed, although they are far from being developed into higher forms. Selfishness and stubborn obstinacy govern the patient's emotional life, and he also becomes irritable and violent in connection with the attacks. His own person first and then his family always ■ occupy his thoughts, while his sympathy for others is in abeyance. 16 242 Lectures on Clinical Psychiatry But he shows a certain external piety, such as we very often find in epileptics. And that he does not take too dark a view of his future, in spite of his hypochondriacal fears, but has " only slight attacks now," exactly coincides with our general experi- ence of such patients. Lastly, the painstaking accuracy in details shown in the patient's sketches is often a very marked feature in epileptics. All these peculiarities together constitute the characteristic condition known as epileptic feeble-mindedness, which generally develops more or less where the illness has been severe and is of long standing. In many respects, it very much resembles congenital feeble-mindedness, but differs from it essentially in the feeling of illness expressed. Often enough this mental weak- ness develops with alarming rapidity, and it may reach a very high degree in the course of a few years. In the case of our patient, in whom it has evidently made a great advance lately, we must be prepared for its further development in an unfavour- able direction. The recognised remedies for epileptic seizures,, particularly bromides, are not able to relieve this condition,, and do not even seem to check its development.* A girl, aged twenty-six, who was sent here five weeks ago from the hospital for women, has presented great difficulty in diag- nosis. The patient, who was advanced in pregnancy, and was waiting in the hospital for her confinement, became restless, confused, and apprehensive, and ran about aimlessly during the last few days she was there. It was on that account that she was sent here. The gradual development of this condition was pre- ceded by two " attacks." At our hospital the patient was unable to remember anything, and when questioned only answered, " I do not know," but talked to herself a great deal, slowly and with a rhythmic accent, as if she were speaking to someone else. The purport of her talk was quite confused : " Ay, what am I to do then ? Ay, what are you doing, then } Ay, so I must die. Ah, where must I go, then, if I cannot die ? Fine schoolhouse — always to stay sitting. Ah, where am I to go then ? I can always sing. Ah, so the mouse is dead — yet I cannot find it. I can always die. Ah, I must always dance — I have pretty stockings on," etc. Sometimes she answered relevantly, but * The patient has been for five and a half years in a nursing asylum, and still has attacks and delusions of reference. He works, and is able; to do arithmetic, but in other respects is very imbecile. Epileptic Feeble- Mindedness 243 quite incorrectly — that she was a hundred years old, or thirteen, that she was at Mannheim, that her child was the Emperor's. She prattled in an incoherent way all the time, and often seemed not to understand the questions at all, but tried to connect her answers with remarks made by those around her. Her mood was indifferent and changeable. Sometimes she seemed afraid of being beaten, and sometimes showed an inclina- tion to sing and dance. She obeyed orders at once, and wrote her name and words dictated to her slowly, but in legible, careful writing. But a letter she had to write proved to be a variegated collection of single words and confused recollections of what she had read, ending in an interminable row of figures. Though automatic obedience could not be made out, the patient put out her tongue, without hesitation, to have it pierced. Apart from the signs of her late pregnancy, a great diminution of sensibility over the whole body was the only physical sign worth noticing. As we had no details of the previous history of the case, a number of diseases might have come under consideration in the interpretation of the patient's condition. The " attacks " which had occurred gave us no definite clue, as they might just as well have been hj'sterical as epileptic, katatonic, or paralytic. The patient's great mental awkwardness, the difficulty of influencing her, and the absence of strong emotional fluctuations, seemed to us to exclude hj^steria, and the picture was altogether wanting in the rather theatrical propensity which seems to be characteristic of hysterical states of semi-consciousness. The patient's talk and writing reminded us very strongly of katatonia, but we missed the negativism, absurd behaviour, and automatic obedience. The patient evidently understood with great difficulty, in spite of her good will. This is the opposite of the good comprehension and want of attention in katatonia. The slowness and want of sense in her answers seemed to us to depend on defective memory and not on negativism, since she evidently took trouble to answer to the demands made on her. This feature of her behaviour led us to think of the possibility of general paralj^sis. We believed, however, that we ought to reject this hypothesis. In the first place, there was an absence of all tangible physical disturbances, except the analgesis, the general extent of which would have pointed to general paralysis rather than to hysteria. But the patient's answers were much more senseless and confused than could have been expected in a 16 — 2 244 Lectures on Clinical Psychiatry paralytic of the same mental activity. This disproportion indi- cated a state of semi-consciousness rather than paralytic feeble- mindedness. At the most, it could only have been taken for bewilderment after a paralytic attack, but the patient's stupefac- tion was not deep enough for that, and the signs of disablement to be expected in such a case were absent. Under these circum- stances, the hypothesis of an epileptic state of semi-consciousness seemed to us the most reasonable. We therefore expected the disturbance to disappear very soon. The clouding of consciousness did, in fact, disappear in the next few days, and we then learned that the patient, whose mother is " nervous," has suffered from attacks of convulsions since she was fifteen years old, recurring every three or four weeks, and then coming in groups, with complete insensibility and occa- sionally with tongue-biting and other physical injuries. Now and then the convulsions did not appear, but states of stupefac- tion and bewilderment took their place, lasting about a week. The patient was backward in her mental development, and did not learn much in consequence of her malady. If we now look at the strongly-built and well-nourished patient, who passed through the puerperium without difficulty, we notice at once that she is quite clear and well ordered, but is mentally on the level of a child ten or twelve years old. She understands simple questions correctly, and answers them relevantly, but shows a very limited mental horizon, extremely little knowledge, and great weakness of judgment. She knows nothing of all those things and relations of things which lie outside her immediate daily surroundings. Her phraseology is awkward, over-circum- stantial, monotonous, and meaningless. In the numerous neatly- written letters she has addressed to her relations the number of phrases of greeting and leave-taking is very noticeable. She is quite unconscious of the meaning of her pregnancy, and tells us childishly how she got fatter and fatter from eating a great deal, till at last she could not fasten her clothes. Her mother would not take her out with her on Sundays then, so she got on the stool and looked out of the window. It was quite true that she had had a sweetheart ; he always said, " You are a good girl." Her friend had said to her that she would not go with him, because he carried on with other girls: So she wrote and refused him, and then her friend went with him. The child was her father's. The Saviour appeared to her, and told her that she Epileptic Feeble-Mindedness 245 should not be beaten, that she was a good girl, and that the child was her father's. She holds obstinately to this story. Her mood is on the whole exalted. She is only disappointed that since the birth of her child, from which she confidently expected an improvement in her health, the attacks have appeared again. " But," she says, " it only last? quite a short time now." In reality, she has already had several very severe attacks. The patient is orderly in her behaviour, easily guided and good- tempered, and occupies herself industriously of her own accord. You will easily see in this patient the characteristics of epilep- tic feeble-mindedness enumerated above — mental clumsiness, poverty of thought, narrowing of the mental horizon, want of judgment, exaggerated self-esteem, pleasurable hopes, piety, and formality. But strong emotional irritability has not been noticed — at any rate, in the short time she has been under observation. I must add here that, contrary to the general opinion, most epileptics are by no means always irritable, but only at certain times, while in the intervals they are often quite good-tempered and ready to help, though usually in an awkward and unintelH- gent way. As our patient's relations wish to take her home soon, we will not think of beginning treatment with bromides, from which we could expect but little in any case. The patient can easily begin it at home, if she is placed under regular medical supervision. Under no other circumstances can we advise it, as the danger of chronic bromide poisoning must not be overlooked. To consume large quantities of bromides without a doctor's pre- scription, as is often done, is a very dangerous measure.* While the illness went back to childhood in the two cases already discussed, I will now show you a carpenter, aged fifty, who only became epileptic a short time ago. He is said to belong to a healthy family, is married, and has three healthy children, while four have died in infancy of convulsions. He has always drunk a great deal, but worked regularly. Twenty years ago he fell down two stories from a new building under construction, and lay insensible for several days, but got quite well again. During inflammation of the lungs, which he had eight years ago, he was dehrious, and twice escaped to go to work outside. Three years ago, without any external cause, a dehrious condition again set in, with headaches and apprehension, and lasted a fort- * Two months after her discharge from the hospital the patient upset a lighted petroleum lamp during an attack, and was burned to death. 246 Lectures on Clinical Psychiatry night. Since then the patient has periodically often been irritated with those around him. At these times he accused his wife of unfaithfulness, and threatened and ill-treated her, while he got on with her very well in the intervals. Six months ago he became giddy while at work. In going home, he fell and hurt his fore- head, and began to be delirious and violent. When he was brought to the hospital on this account he was clear, but in a very surly mood. He could remember neither the attack nor his excitement, and only said that he had " had it in his head." " What it was I do not know." About a week seemed to be missing from his memory. He complained then that he often felt pricking and twitching in the old scar he got from his fall, and then grew giddy and confused, so that he could not help dropping whatever he had in his hand in the middle of his work. Often he did not know anything afterwards of what had happened. His ill-temper disappeared in a few days. Later on he again complained a few times of passing attacks of giddiness, but in other respects he presented nothing remarkable except distinct feeble-mindedness. He was therefore discharged after having been kept under observation for several weeks. Very soon afterwards, however, an epileptic attack of con- vulsions came on outside, and recurred regularly about every five or six weeks. Sometimes several attacks came on in rapid succession, and the patient was often confused for several hours afterwards, running about aimlessly and talking nonsense. Five weeks ago he became sleepless, very much irritated without any cause, violent to his wife and children, and bewildered. He said he was in heaven, preached and prayed in the night, forced his family to pray with him, and finally, a week later, set fire to his bed while in this condition, and so was brought back to the hospital. On admission, he was still not at all clear. He knew his surroundings, but spoke of wanting to go down to the work- shop, and said that he had " had it in his head again." The attack had begun with apprehension, a freezing sensation, and giddiness. He saw a bird fly to him, heard singing, music, and bells, and could not remember anything more. He remembered the fire, but did not know how it arose, and it was only later on that he had a dim recollection of having tried to make coffee. You see that the patient is quite clear now, well ordered in his ideas, and intelligent, but shows a certain dulness of understand- ing and of thought. He has to think a good while over even Epileptic Feeble-MIndedness 247 simple questions, and is very uncertain in respect of events which are at all of a distant date. He can give hardly any details of his illness. He knows practically nothing about the actual attacks, except from the descriptions of those around him, and has apparently not asked much about them. He also speaks of giddiness and a feeling of heat in his head as coming on occa- sionally and always lasting for several hours. He does not talk much, and is rather wanting in ideas, but is natural and in no way remarkable in his behaviour. He occupies himself regularly of his own accord. He tries to make his drinking seem quite harmless. The old scar on the right side of his forehead is pain- ful to touch, and so, in a less degree, are the surrounding parts. But it is not possible to bring on an attack by pressure here. It cannot be said with certainty whether the old injury to the head is in any way the cause of the epilepsy. The length of time that elapsed makes it impossible to assume a connection, except on the hypothesis that slight attacks or night attacks took place in the interval, unnoticed by the patient or those around him. It is also possible that an attack may at the very first have been the cause and not the result of the fall, as may in reality often be the case where at first sight the epilepsy seems to have been caused by an injury to the head. Here, however, another important influence has been at work — that is, alcohol. There is no doubt that this can give rise to severe attacks of convulsions, yet it must be considered questionable i^^ we should be justified in classing these attacks together with ordinary epilepsy. In its clinical appearance what is called " alcoholic epilepsy " is distinguished from the other and genuine forms by the occurrence of attacks of convulsions alone, and those in their most severe form, while the numerous " equivalents " of other kinds — slight attacks, states of semi-consciousness, ill-humour, etc. — play no part at all. On the other hand, it is undoubtedly certain that alcohol regu- larly has an injurious and provocative effect, even in genuine epilepsy. After such experience, we can hardly consider alcohol to be the real and only cause of the disturbances in the case before us, with its various kinds of epileptoid manifestations. It is, however, conceivable that the original fall may have left behind it a certain disposition to epilepsy which afterwards developed further under the injurious influence of drink. Very likely the patient's ideas of jealousy should be set down to the score of alcohol, and it is 248 Lectures on Clinical Psychiatry possible that it was delirium tremens which had to be dealt with in the mental disturbance during the inflammation of the lungs. This cannot be the case, however, with regard to the later delirious attacks, even though there are certain features to suggest it. The long duration of the condition three years ago, the very definite religious colouring of the last attack, the con- fusion of memory, and the absence of a humorous mood, all contradict this. But, of course, we will have to recommend total abstention from alcohol to our patient most emphatically. Whether he can and will follow this advice is, unfortunately, more than doubtful.* * The patient died of consumption at home a few years later. LECTURE XXV HYSTERICAL INSANITY Gentlemen, — ^The young lady, aged thirty, carefully dressed in black, who comes into the hall with short, shuffling steps, leaning on the nurse, and sinks into a chair as if exhausted, gives you the impression that she is ill. She is of slender build, her features are pale and rather painfully drawn, and her eyes are cast down. Her small, manicured fingers play nervously with a hand- kerchief. The patient answers the questions addressed to her in a low, tired voice, without looking up, and we find that she is quite clear about time, place, and her surroundings. After a few minutes, her eyes suddenly become spasmodically shut, her head falls forward, and she seems to have fallen into a deep sleep. Her arms have grown quite limp, and fall down as if palsied when you try to lift them. She has ceased to answer, and if you try to raise her eyelids, her eyes suddenly rotate upwards. Needle- pricks only produce a slight shudder. But sprinkling with cold water is followed by a deep sigh ; the patient starts up, opens her eyes, looks round her with surprise, and gradually comes to herself. She says that she has just had one of her sleeping attacks, from which she has suffered for seven years. They come on quite irregularly, often many in one day, and last from a few minutes to half an hour. Concerning the history of her life, the patient tells us that her parents died sixteen years ago, one soon after the other. Her father's step-brother attempted suicide, and her brother is most fantastically eccentric. I must add that two other members of her family give the impression of being very nervous. She did her work easily at school. She was educated in convent schools, and passed the examination for teachers. As a young girl, she inhaled a great deal of chloroform, which she was able to get 249 250 Lectures on Clinical Psychiatry secretly, for toothache. She also suffered from headaches, until they were relieved by the removal of growths from the nose. She very readily became delirious in feverish illnesses. Thirteen years ago she took a place as governess in Holland, but soon began to be ill, and has passed the last seven years in different hospitals, except for a short interval when she was in a situation in Moravia. It would appear from the statements of her relations and doctors that the patient has suffered from the most varied ail- ments, and been through the most remarkable forms of treat- ment. For violent abdominal pains and disturbances of men- struation, ascribed to stenosis of the cervical canal and retro- flection of the uterus, recourse was had five years ago to the excision of the wedge supposed to cause the obstruction, and the introduction of a pessary. At a later period loss of voice and a contraction of the right forearm and the left thigh set in, and were treated with massage, electricity, bandaging, and stretching under an anaesthetic. Heart oppression and spasmodic breathing with quickly passing disablements of various sets of muscles, distur- bances of urination, diarrhoea, and unpleasant sensations, now in one and now in another part of the body, but particularly headaches, also appeared. Extraordinarily pronounced and sudden changes of mood were observed at the same time, with introspection and complaints of want of consideration in those about her and in her relations, although the latter had made the greatest sacrifices. Brine baths, Russian baths, pine-needle baths, electricity, country air, summer resorts, and, finally, residence on the Riviera — everything was tried, generally with only a brief improvement or with none at all. The immediate cause of the patient being brought to the hospital was the increase in the " sleeping attacks " two years ago. They came on at last even when the patient was standing, and might continue for an hour. The patient did not fall down, but simply leaned against something. The attacks continued in the hospital, and spasmodic breathing was also observed, which could be influenced by suggestion. Hypnotic experiments only produced hypotaxis, suggestions of cure proving not to be lasting. But sprinkling with cold water and the faradic current were fairly effective, even against the disablement which appeared now and then. After spending eight months here, the patient went away at first to her sister's. But after a few months she Hysterical Insanity 251 had to be taken to another asylum, where she stayed about a year, and then, after a short time spent with her family, came back to us. During her present residence here, so-called " great attacks " have appeared, in addition to her previous troubles. We will try to produce such an attack by pressure on the very sensitive left ovarian region. After one or two minutes of moderately strong pressure, during which the patient shows sharp pain, her expres- sion alters. She throws herself to and fro with her eyes shut, and screams to us loudly, generally in French, not to touch her. " You must not do anything to me, you hound, cochon, cochon !" She cries for help, pushes with her hands, and twists herself as if she were trying to escape from a sexual assault. Whenever she is touched, the excitement increases. Her whole body is strongly bent backwards. Suddenly the picture changes, and the patient begs piteously not to be cursed, and laments and sobs aloud. This condition, too, is very soon put an end to by sprinkling with cold water. The patient shudders, wakes with a deep sigh, and looks fixedly round, giving only an impression of being tired and sense- less. She cannot explain what has happened. The physical examination of the patient shows no particular disturbances at present, except the abnormalities already men- tioned. There is only a well-marked weakness, in consequence of which she often keeps her bed or lies about. All her movements are limp and feeble, but there is no actual dis- ablement anywhere. She often sleeps very badly. At times she wanders about in the night, wakes the nurses, and sends for the doctor. Her appetite is very poor, but she has a habit of nibbling between her meals at all kinds of cakes, fruit, and jam, which are sent to her, at her urgent request, by relations. What particularly strikes us in this picture is, first, the coming and going, in the form of attacks, of a number of disturbances of different kinds, and, secondly, the fact that they are influenced by external agencies. These two peculiarities show at once and with absolute certainty that we have to deal with the disease here known as hysteria. Its nature is, I think, to be found in this: that all disturbances on the mental side arise, with very strongly- exaggerated sensations, through the agency of ideas. There is not one of the very varied appearances which might not be called up by violent emotional shock. All that is morbid is the circum- 252 Lectures on Clinical Psychiatry stance that these disturbances appear even when there has been no cause, or only a very trivial one, for emotional excitement. In the " great attacks " occurrences are repeated in dream-like recollection which the patient says have taken place before. These are, first, a gynaecological examination, to which she was very roughly subjected by a Dutch doctor, and, secondly, a curse pronounced on her by her aunt. That all the disturbances are produced by ideas having the force of sensations is very clearly shown by the fact that they can at once be put an end to by psychical influences. A contraction of the patient's right hand, provoked by her former doctor by an incidental question about the disturbance, which had often been observed before, was very instructive. Next day the hand was so spasmodically clenched that the nails ran into the skin. After a little instruction in metallo-therapeutics, first a gold coin and then a key was laid on the wrist and relieved the spasm. The faradic brush worked even better, and had a more lasting effect. While real hypnotics had hardly any influence, her sleep was very much improved by distilled water, with harmless addi- tions, and by powdered sugar. All the other various troubles gave way to measures of the same kind, working on the imagina- tion alone. It is true that these results were only temporary, as was to be expected, considering how changeable were the patient's feelings. After a few hours or days, with or with- out an external cause, one or other of the old symptoms returned. The capricious nature of hysterical phenomena leads only too easily to the accusation of intentional and artful trickery. But many of the disturbances observed can hardly be imitated voluntarily, or cannot be imitated at all, while others are only accidentally discovered, and have never come to the patient's own knowledge — as, for instance, the limitation of particular departments of perception. These circumstances seem to me to confinn the hypothesis that in this disease we have always to deal with the involuntary effects of excited sensations, referable to the patient's own body. Again, the morbidity of the general condition, even when dis- turbances are really feigned or greatly exaggerated, is shown by the patient's whole course of life. Our patient, in spite of her very good mental endowment, has never been able to fill any place in hfe permanently, but has been wandering for many years out Hysterical Insanity 253 of the hands of one doctor into those of another. In this we recog- nise the deep disturbance of the will, which we never fail to see in hysterical patients. In spite of the usual extravagant com- plaints about her illness which our patient is always pouring out to the doctors in conversation or in letters, she is quite without the power of striving energetically to overcome the morbid phenomena. Indeed, her illness gives her a certain satisfaction, and she resists involuntarily when steps are taken to cure it. Hence the constant appearance of new and ever more remarkable disorders ; hence the exaggerations, the calls for the doctor, and the burning desire to see proper attention given to her own con- dition, because invalidism has essentially become a necessity 0} life to her. With her growing expertness in illness, the emotional sjnn- pathies of the patient are more and more confined to the selfish furthering of her own wishes. She tries ruthlessly to extort the most careful attention from those around her, obliges the doctor to occupy himself with her by day or by night on the slightest occasion, is extremely sensitive to any supposed neglect, is jealous if preference is shown to other patients, and tries to make the attendants give in to her by complaints, accusations, and out- bursts of temper. The sacrifices made by others, more especially by her family, are regarded quite as a matter of course, and her occasional prodigality of thanks only serves to pave the way for new demands. To secure the sympathy of those around her, she has recourse to more and more forcible descriptions of her physical and mental torments, histrionic exaggeration of her attacks, and the effective elucidation of her personal character. She calls herself the abandoned, the outcast, and in mysterious hints makes confession of horrible, delightful experiences and faihngs, which she will only confide to the discreet bosom of her very best friend, the doctor. Hysterical insanity is the expression of a peculiar, morbid tendency, and can be brought to further development, but not originated, by external causes. In our patient, the beginning of the illness goes back to an early age. We cannot therefore expect that treatment will be successful in altering her personality. Such patients, in whom the selfish development of feeling and will has appeared, in addition to the other symptoms of hysteria, are generally permanent thorns in the flesh of their relations and doctors. The individual manifestations of the disease may 254 Lectures on Clinical Psychiatry change, but the original soil remains unaltered in which ever liew and exaggerated phenomena of the disease are generated.* The case of a little girl, aged five, who was brought here a few days ago will show how far the first signs of hysteria may date back. The child is small for her age, but well nourished. In the bent tibia and thickened epiphyses you recognise the traces of former rickets. The child understands us well, is lively and affectionate, recognises the pictures and objects she is shown quickly and with certainty, and gives read}' answers, though perhaps her knowledge is rather limited for her age. We are struck by a certain restlessness, a tendency to play about and chatter and make faces. Her mood is generally cheerful, but quickly turns to tears and angry stubbornness. Her amorous tendencies are plainly seen. She likes to hold and stroke the hands of the doctors, declares that she is quite particularly fond of them, holds her hands before her face in fun, and peeps between her fingers, and tries to draw attention to herself. She is natural in her general behaviour, eats neatly, is fond of playing, and keeps herself clean. She has soon grown quite familiar with her surroundings. It is generally difficult to get the little girl to bed in the evening, as she would much rather sit up and amuse herself. She grows very naughty then, sometimes, and cries and scratches if she cannot have her way. The child belongs to a healthy family, but has suffered much from rickets. She was brought to the hospital on account of attacks which set in two years ago after influenza. The attacks began with stomach-aches, breathlessness, flushing of the head, perspiration and palpitation, after which she fell asleep and became pale and deathlike. She could be aroused by sprinkling with water, but could not remember what had happened. Similar attacks occurred from that time onwards, at first at intervals of several weeks, but aftenvards more and more frequently, and at last in series of five or six in one day. The last attack but one occurred four weeks ago. The child was then taken to an infirmary, where the attack again occurred a fortnight ago. No more have since been observed. The child is said to be backward in her mental development, and to have forgotten much that she used to know. She was treated for some time for infectious colpitis, which she caught from a little friend. * The patient died of pulmonary consumption after having been one year in the asylum psychically unchanged. Hysterical Insanity 255 Unfortunately, we have not been able to witness an attack for ourselves. But it can hardly be doubted, from the description, that they were hysterical. This appears from the mild form of the seizures and the brief time they lasted, the possibility of cutting them short by sprinkling with water, their extraordinary frequency of late, and their almost complete cessation in the infirmary, after they had been recurring at intervals of only three or four days. Besides these attacks, there is a peculiar alteration of character — great liveliness, sudden changes of mood, the inclination to attract attention to herself, and defective mental development — features we often find in children who are morbidly disposed and have been reared with difficult3^ Even if we should be justified in attributing the not very marked arrest of mental development principally to the child's ill-health, the other peculiarities quite resemble those we see in adult hysterical patients. They may therefore be closely connected with the ailment of which the attacks are the expression. The serious alteration of the child's whole character points to the possibility of a further development of the illness later on. General experi- ence shows that slight signs of hysteria very often occur in children, with their great emotional susceptibihty, without more severe hysterical illness necessarily following. The disturbances often disappear entirely with appropriate psychical treatment. As a rule, the best result is obtained by removal from the family to other surroundings, or perhaps to an infirmary, by ignoring the disturbances, and, lastly, by some simple treatment by sugges- tion, with or without hypnotism, which often has speedy and permanent results in children, though in adults they are generally only temporary or are altogether wantmg.* Hysteria, as is shown by the derivation of its name from the Greek for " womb," was formerly considered a disease of the female sex. It is true that, on account of the greater emotional excitability of that sex, its physical and mental processes are more easily influenced by those ideas having the force of sensations which are the key to the comprehension of hysterical pheno- mena. Still, male hysteria is by no means uncommon, though its manifestations are, on the whole, less varied. Now I will show you a man, aged fifty, who was admitted nearly a month ago for the examination of his mental condition, after having * The child was sent to an asylum for idiots a few years later, and was discharged from it in six years well developed. 256 Lectures on Clinical Psychiatry committed arson without recognisable motives and in a senseless way. He had come home in a state of intoxication, and soaked all kinds of old lumber with petroleum in the attics of the house where he lived and also on the floor beneath. He had set fire to some of this, and precisely to those things which did not belong to him. He gave an evasive answer to his wife, who was very ill, and asked him where he had been. Then he got into bed. The fire, which might easily have grown to large proportions and endangered the life of his own daughter, was very soon discovered, and so were the marks of his stockings, soaked in mineral oil, leading to his bedroom. When he was arrested, the patient admitted his guilt, but could not remember the details of the deed. The patient's mother was insane, and his nephew was an inmate in this asylum. When he was nineteen years of age he had an acci- dent and hurt his head. He had another accident twelve years ago, when he broke two ribs. Since that time he has been changed. Immediately after the second accident his whining, apprehensive disposition excited remark. He complained very much of pains and oppression, and, although medical examination gave no adequate explanation of them, he feared that he would never be able to work again. His capacity for doing anything did, in fact, remain permanently impaired, so that he drew sick-pay to the extent of from 30 to 50 per cent, of his former earnings. He only worked occasionally, generally letting his wife support him. He wandered aimlessly about in the town, sat in public- houses drinking, and sometimes took small sums from the family money-box to get drunk with, although his family were falling into more and more embarrassed circumstances. Attacks often came on, more especially when he had been drinking, in which he threw himself on the ground, hit out all round him, and became breathless. Latterly his memory failed, and he made no attempt to earn money, but left everything to his young and delicate daughter. On his admission to the hospital, the patient was rather con- fused, and had to think for a long time before he could remember simple things. He was not half the man he had been, as he said himself in a tearful mood. Physically, we were struck by im- paired sensation over his whole body, increase of the reflexes, chewing, scanning speech, very strong tremors in the limbs, and clumsy awkwardness in all grasping movements. During the next few days great restlessness set in, with vivid hallucinations of Hysterical Insanity 257 sight. The patient saw animals, particularly blackbeetles, running and flying about in quantities, and at such times lost all clear idea of where he was. It was almost a week before he recovered his bearings as to time, place, etc., on the disappear- ance of the hallucinations. Evidently this was an attack of delirium tremens. After it had passed off, attacks were twice observed which answered to his daughter's description. The patient complained of being unwell, sank to the ground, stretched himself out stiffly, hit out round him with his arms, threw him- self about, and bored his head back into the pillows. His eyes were convulsively shut and the pupils dilated, with impaired reaction to light. When the eyes were forcibly opened, the eyeballs suddenly rotated upwards. Pricking with a needle, sprinkling with water, and touching the lips with quinine solution produced defensive movements. The approach of the doctor to the bed aggravated the attack, while the patient grew quiet as soon as he was left unnoticed. Recollection of the attacks seemed entirely extinct afterwards. At present the patient is collected, clear, and well ordered, though rather clumsy in his statements. He tells us, at great length, about his accidents and the troubles to which they have given rise. He has little general knowledge. His mood is rather inconsistent with his position, for he does not worry much, and has all kinds of plans and good resolutions for the future, though he is easily made to cry. Stuttering speech can still be observed, with very strong tremors of the hands and awkwardness of move- ment, which evidently increase if his attention is called to them. This makes his writing almost illegible. Sensibility to touch and needle-pricks is somewhat reduced over the whole body, without its being possible to mark out any particular region as specially anaesthetic. Sensations of smell and taste can be excited only slowly and feebly. The field of vision is reduced by more than one-half. The attacks observed admit of no other explanation than that our patient is suffering from hysteria. The other physical dis- turbances can also easily be reconciled with the description of this disease. It is specially to be noticed that both the attacks and the disturbances of consciousness can be influenced in a very noticeable way by the doctor. The difficulty in writing, in par- ticular, was very much improved by a few hypnotic seances, so that its psychical origin is established with absolute certainty. 17 258 Lectures on Clinical Psychiatry As all the disturbances can be traced back to the second accident, we very probably have a case of traumatic hysteria before us. It is important that there was no concussion of the brain worth mentioning at the time. The weakness of the arm, the tremors, and the attacks cannot, of course, have been caused by the fracture of the ribs in itself. Hence it is quite clear that the shock alone is to be regarded as the cause, or rather the occasion, of the hysterical change. The patient may have committed the arson in a hysterical state of semi-consciousness, which apparently set in under the influence of alcohol. This quite accords with ourgeneral experi- ence. We know, not only that arson is very common in states of hysterical semi-consciousness, but also that alcohol greatly favours the development, both of hysterical disturbances in general and of particular attacks. The delirium tremens observed by us was a further result of our patient's abuse of alcohol. We must also credit the poison with an important share in the mental and moral feebleness which has developed in the patient in the course of time, and is quite in agreement with the recognised deterioration of drunkards. Finally, we would mention that the disturbances were not re- moved, or even alleviated, as is often the case, when the patient's income was assured. For this, too, the alcoholism is probably responsible. It has continually been causing the patient fresh cares, and has greatly reduced his power of resistance. It is possible that permanent and complete deprivation of alcohol may still produce a certain improvem.ent, but we cannot overlook the fact that the patient's prospects are rendered very dark by the signs of mental weakness.* * The patient's condition gradually improved very much in the hospital, although a certain degree of weakness of judgment and love of emotional excitement remained. In consideration of his dangerous character, he was transferred after six months to a nursing asylum, from which he was. eventually discharged. LECTURE XXVI INSANITY AFTER INJURIES TO THE HEAD Gentlemen, — We have already repeatedly had occasion to point to the causal importance of severe injuries to the head as the origin of mental disturbances. It cannot, of course, be denied that very often one has perhaps too readily assumed a connection of that kind, especially if long spaces of time lie between the accident and the gradual development of the mental disease. We still know so miserably little about the true causes of insanity that we must be extremely cautious when conclusions as to cause and effect have to be deduced from a lax sequence of time. We shall be entitled to such an assump- tion if the mental disturbance follows closely on the injury, but especially so if the clinical peculiarities of the case accurately resemble those we have learnt to recognise in other observations of absolute certainty. The case of the tinsmith of forty-four years of age who was brought here a week ago from the surgical hospital illustrates both these conditions. Three weeks ago, as he was going out towards midnight to fetch some water, the patient tripped on the steps and fell down. He was found un- conscious, and only gradually came to himself next morning. Some blood flowed from the right ear. Towards mid-day the patient had several attacks of vomiting, and was said to have thrown up about a tablespoonful of blood each time. As to his previous life, there is only to note that for many years he drank deeply' from time to time, but could never stand much ; he was irritable at such times, and often violent to his wife. At the surgical hospital, where he was first taken, they found a large contused wound, about the size of a three-mark piece, over the right parietal bone, with swelling and suffusion of blood round it. The right external ear was much contused, and the 259 17 — 2 260 Lectures on Clinical Psychiatry whole of the right side of the head, as far down as the mastoid process, was very painful. A small clot was found in the external meatus. Lastly, the region over the third and fourth ribs on the left side was painful. No disturbances which would have pointed to a circumscribed injury to the brain could be made out, but the patient was in a certain state of excitement which made a more accurate examination very difificult. He was quite confused as to time, remembered nothing at all about the more exact particulars of his fall and of events since then ; also he had no grasp at all of his serious condition, desiring to be allowed to go home, because he had to attend to his work, wished to have his clothes, resisted all interference, tore off the dressing, and got out of bed at night. The wound healed quickly, and the pain disappeared after a time, but the rest- lessness and confusion of the patient continued. He spoke of letters which he had received, had no idea how long he had already been in the hospital, and, finally, escaped one night in his shirt and slippers, to hide in a neighbouring new building, where he thought his brother-in-law had told him he would be waiting for him with his waggon. In consequence of this incident he was brought here. As you will see, the rather poorly-nourished, pale-looking man understands the questions addressed to him, even if a certain loss of memory has to be admitted. He knows where he is, knows the doctors, and remembers the occurrences of the last few days quite well. But his ideas of time are quite confused. Even if one puts him right as to this he very soon forgets it again. On the other hand, he says that he had a visitor yesterday, and that his wife has promised to fetch him away to-day, both state- ments being untrue. He works out sums that can be done with the help of the multiplication table correctly, but easily gets confused so soon as he has need for mental effort and the marking down of figures. The fact is very striking that he knows almost nothing about his residence in the surgical hospital, and especially about his fall. He gives various freely- invented versions of his case. One time he says that he had fallen down in the factory at three o'clock in the afternoon ; another time, shortly afterwards, that he had quickly sprung down three steps on to an iron plate, with a little screw, in order to reach the piston. On being questioned more particularly, he ornaments these occurrences with all manner of details, Insanity after Injuries to the Head 261 evidently convinced that he is giving a true account. But all his statements are singularly vague and indistinct. He has no feeling at all of illness, and urges unintelligently that he must get to work at any cost. He will lose his place if he does not go, for they will think he wishes to shirk. His mood is rather lachrymose, but without deep emotion. He takes the fact that he is in a lunatic asylum quite calmly, and betrays little interest in what goes on around him. The physical examination of the patient shows a recent, non-adherent scar at the edge of the tabular part of the right occipital bone, as well as some smaller scars on the left temporal and parietal bones. The skull is asymmetrical ; the features are rather flabby. No nervous disturbances are to be estab- hshed which would point out a central seat of disease. The knee-jerks are moderately active ; also the mechanical excita- bility of the muscles is increased. As the hearing appeared to be impaired, especially on the left side, a more exact report upon the ear was deemed advisable. Certainly this showed the probability of a double-sided affection of the labyrinth, but, after the aurist's examination, it could not be brought directly into connection with the fall sustained. The patient showed great fatigue from the various physical examina- tions. The mental disturbance, which in this case followed immedi- ately on the loss of consciousness after the fall, is essentially distinguished by difficulty of thought and comprehension, and further by the gap in the memory as to the injury itself, by considerable disturbance of attention, and, lastly, by the setting in of spurious acts of memory in place of the real recollections, which were destroyed. The absence of feeling of illness is very curious. According to my opinion, we might, with tolerable certainty, regard those features as diagnostic of mental dis- turbances after severe concussion of the brain. So that the clinical picture would also be in favour of the causal connection between the fall and the insanity. As conditions of this kind can dis- appear after some time without leaving any distinct traces, there is evidently a question here of changes in the cerebral cortex, which are not irreparable : little haemorrhages and lacerations, and also, perhaps, subtle alterations in the structure of the nerves themselves. Therefore, as fever and appearances pointing to a central lesion are absent in the case we are now 262 Lectures on Clinical Psychiatry- discussing, we may venture to hope for a gradual adjustment of the disturbances still existing.* The case of the day labourer, aged eighteen, upon whom we have to pass an opinion with regard to his being able to work for his living, will serve to show you what may be the future fate of such patients who have suffered from a severe injury to the head. The patient, who comes of a healthy family, and who, with average talents, was industrious and well-behaved at school, eighteen months ago was trying to come down a ladder from the fourth story of a new building. As the ladder slid on the slippery support, he sprang off, but missed the scaffolding- planks, and fell as far as the first story, striking the right side of his forehead. He was brought home apparently dying. The right side of the face was very much swollen ; blood flowed from the mouth and nose. The patient was completely uncon- scious, and only after some days came to himself. After the swelling of the face had subsided, it was seen that the sight of the right eye was entirely lost. The patient complained, in addition, of headache and continual cough. It was said that he had also vomited some blood. The condition improved gradually, though his father had already noticed, during the first few months, that he was changed in his whole nature. The once good-natured and tractable lad was easily made angry, and was very excitable, had a tired expression, and was no longer of use for work of any kind. Sleep and appetite were good, but small quantities of sugar were found regularly in the urine. The patient himself complained much of feelings of giddiness. The examination of the eyes showed atrophy of the optic nerve and changes in the choroid of the right eye, and at the same time almost complete blindness. A fracture of the roof of the orbital cavity, involving the groove of the optic nerve, was considered to be the cause of this disturbance. In the further course of the case, according to the father's account, certain changes in the psychical province developed also. The patient became forgetful, could remember nothing, and behaved like a little child, did no work, ran about aimlessly, and had to be looked for, because he did not come home at proper * We were able to allow the patient to leave the hospital after four weeks' residence. He had still some difficulty in thinking, and was without remembrance of the accident, but otherwise was quite clear. He has now been well for nine years. Insanity after Injuries to the Head 263 times. He played with children, would stand for hours together looking at some canaries, and showed no inclinations consonant with his age. " His understanding does not grow with him," said the lather in a very significant way. Occasionally he was said to have had days on which he was very fretful and irritable, " played the fool, and was very silly," addressed older people as " thou," and behaved with impropriety generally. If we now look at the slightly-built and moderately nourished young man, we can no longer see any external trace of the accident, but the right eye is blind, and slight paresis of the abductus muscle also appears to exisv. The right side of the face looks a little more flabby than the left. The tendon reflexes in the arms and legs are very active ; the hand-grasp is stronger in the left than in the right. But neither movements nor sensibility show disturbance of any kind whatever. The urine shows I per cent, sugar, which we have reduced by one-half by suitable nourishment. The patient is collected, clear as to time, residence, and his position, and gives consecutive information in answer to the questions addressed to him. Since his accident he has suffered from headaches, and is very forgetful. From time to time he becomes giddy, everything goes round in a circle, but without his falling down. Work has become very difficult to him. His knowledge of arithmetic is very good indeed, but he knows neither the capital of Baden, nor the names of the Grand Duke or the Emperor, The chief towns of France and Austria are also unknown to him. He can only specify very few of the places and rivers of Germany, He has the most indistinct ideas about the war of 1870. He is able to repeat the Ten Command- ments, but he does not know why the Easter festival is kept. It may appear doubtful whether this deficiency in his know- ledge can be merely looked upon as morbid, for in a treatise by his former teacher which was forwarded to us, it is expressly pointed out that young people who at school have not acquired any matured understanding of the subjects taught often forget everything again that is not recalled in daily life with surprising rapidity. Still, we shall be quite justified in referring to morbid loss of former knowledge the inability of anyone who has left school four years ago and Sunday-school two years ago as an average scholar, at all events, to tell the names of the Prince and of the capital of the country. 264 Lectures on Clinical Psychiatry At the first glance the patient's behaviour presents nothing special. Upon further observation, it can be seen, however, that he has very little inclination to occupy himself, and would much rather idle about. But especially he soon showed an insubordinate arrogance, and would bear no contradiction, was rude and forward to his much older fellow-patients, calling everyone simply " thou," was abusive in ugly terms directly everything was not quite as he wished, and after those outbreaks tried to put himself forward as the aggrieved person. These experiences agree entirely with the father's description. If we take into account the certificate of his former teacher, in which the very praiseworthy conduct of the boy was distinctly emphasized, the father's statement that a change in his nature had taken place since the fall gains in probability. In addition, there is evidence even now of a fractured skull, indicated by the atrophy of the optic nerve and the quantity of sugar in the urine, also similar changes of character have often been observed after severe injuries to the head. Zola has evidently based his well-known description in the " Assommoir " on some such observation. We may, therefore, certainly take it that the patient's forge tfulness, his poverty of ideas, his want of mental activit}^ and, finally, his irritability and loss of finer feelings, are not only morbid, but are directly the results of the injury sustained. The slight attacks of giddiness, about which, of course, we only know from the patient's own statement, would also be in favour of this. Indications of epileptic disturbances after such injuries are not uncommon. Perhaps the patient's ill -temper, mentioned by the father, which reminds us of similar disturbances of the epileptic, would so" far also count, but the statements about it are too vague ; besides, we could establish no periodicity in the very short time we have had for clinical observation. In this case, also, a hcemorrhage in the cranial cavity has appar- ently taken place at once, upon the pressure of which the long duration of the initial loss of consciousness probably depended. Yet it must appear doubtful whether the stUl-existing psychical change may be looked upon as the after-effect of the increase of pressure at that time, possibly as the result of the disturbances in nutrition produced through it. Such mental and emotional states of weakness following injuries to the head seem much more often to occur when a rough laceration and haemorrhage in the Insanity after Injuries to the Head 265 brain tissue has not taken place at all. Much experience is in favour of the fact that a very violent concussion of the brain can lead to subtle damages, which, subtle though they be, pro- duce the particular kind of picture here described, oftentimes enriched by distinct epileptic features, and especially by im- paired capability of resisting alcohol. It is not uncommon for all these disturbances to become more markedly prominent only quite gradually, and even a long time after the injury has taken place. As a rule, the future prospects are unfavourable. Even in those cases where healed-up scars and depression of the bone offer a guide for operative interference, a successful result is usually absent, or only very temporary.* The case of a belt-maker, aged sixty-one, who has been sent to us for an expert opinion as to his condition, will show us that the connection between injury and insanity can be of quite a different kind from that in the two last cases. Eight months ago the patient had an accident on the railway. He was thrown to the ground, together with his wife and his daughter, in a collision in shunting, and was much bruised. The injuries extended to the right knee, the right upper arm, the region of the right malar bone and side of the head, as well as the right metacarpus. From these, however, he quickly recovered. Immediately after the accident the patient, who had been hurled to the ground by the shock, lost consciousness for some moments. When he came to himself, and was looking for his wife and daughter, who had been much more severely injured, a doctor who happened to be there said : " It will be the worst for the husband "; he was " terribly excited." A short time after the patient noticed that a very great change had come over him. He describes with a certain eloquence how very forgetful he was ; people, especially, he could no longer remember. He always felt tired and exhausted, slept even in the mornings in the room, and had to make great efforts to be able to follow general conversation, especially in large gatherings of people. In consequence of this he had to give up his honorary posts, as he could no longer attend meetings. In the public-house, too, he began to feel ill at once ; he could not stand it any longer. He was obliged to come out and go home. He was forced to think a great deal about the accident, and * Unfortunately, we have no further information to give as to the subsequent history of this patient. 266 Lectures on Clinical Psychiatry to discuss it with his relations. He is also particularly troubled by anxiety about his own and his family's future, as the action for compensation against the railway company is still pending. His capacity for work is now sensibly reduced. As a matter of fact, he is happiest in his workshop, but he is unable to continue working long at a time, and his hand has lost its cunning for his trade. He no longer takes any real pleasure in intercourse with others or in mental pursuits, as everything overtaxes him and exhausts him emotionally. He finds reading more difficult than he did formerly ; headaches soon come on, and his eyes close. In speaking, he frequently has the sensation as if some- thing were sticking in his throat. Indeed, the patient often comes to a standstill in the middle of words. His walking also is impeded ; palpitation of the heart is readily induced, as well as pain in the back and violent perspiration. He often has a feeling as though he must fall down ; he cannot get up on to a chair because he at once becomes terrified by the prospect of a fall. The patient's mood in connection with all these disturbances is very depressed. The physical examination of the well-nourished little man shows strong trembling of the eyelids on closing the eyes, trembling of the tongue, slight strabismus, flabby features, and diminution of the knee-jerks on the right side, and the skin- reflexes are much weaker on the right side than on the left. The strength on the right side appears to be distinctly impaired. On shutting the eyes the patient sways greatly, and then falls down ; he is unable to turn round with closed eyes. The sensibility shows no disturbances anywhere. The examination tires the patient extremely little. The pulse is accelerated ; with exertion the face becomes very flushed. An accurate exami- nation of the ear has established a diminution of sensibility in the right auditory nerve. This picture of disease differs at once from the former patient through the important circumstance that in that case, in spite of severe disturbances, the feeling of illness was entirely absent, while in this case the complaints are very emphatic, and the actual traceable disturbances are very insignificant. The one tangible symptom that would be somewhat in favour of a grave affection of the nervous system is the inequality of the tendon reflexes, but it is not to be denied that this may be dependent on the different tension of the muscles. Whether the subnormal Insanity after Injuries to the Head 267 state of the right auditory nerve has especially to do with the accident cannot be decided. From this want of objective signs the whole malady so com- pletely wears the features of psychical origin that the suspicion may even arise as to whether there may not be intentional malingering with the object of obtaining the highest possible compensation for the accident sustained. This question of shamming in psychical affections following accidents has become of great importance, owing to our legislation, and has led to a zealous search after objective demonstrable symptoms in dis- turbances of that kind, though certainly with little result so far, since they have been looked for exclusively in the neuro- logical province. But the complaints brought forward by our patient correspond as a whole with those which might perhaps also be brought about by tormenting anxiety. Therefore they point to their originating from morbid frames of mind. Indeed, the emotional shock — the fright- — doubtless plays the chief part in these clinical manifestations, accurately described by Oppenheim under the name of Traumatic Neuroses. This also happens even if there has been no sort of injury to the head, and, indeed, if there has been no accident at all, but merely the imminent danger of one. This explains the fact that, apart from accidental concomitant appearances of real injuries, only such symptoms occur here as could be caused by emotional agitation. Hence one will never be able to find out, from a purely physical examination, reliable symptoms of the latent malady, which might not have been invented after all. We are in a measure protected from being deceived by malin- gering by the uncommonly rare condition taken as a whole, which shows a continual emotional restlessness, with its effects upon our patient's capability for work, on his pleasure in life, on his mood, and on his physical doings, sensations, movements, daily routine, and so on. As it would appear, this emotional disquietude is to be regarded partly as the after-effect of the violent emotional shock, but also partly as the effect of the " struggle for an income " which so .often, in the most torturing forms, follows an accident. The not unfrequent cases in which a substantial improvement of all disturbances sets in with the certainty of an income is at least in favour of this last opinion. When that is the case one is apt to suspect that there has been a question of premeditated dissimulation with an object. 268 Lectures on Clinical Psychiatry The psychical method of investigation can alone lead in the right direction towards meeting this suspicion, and finding out a way which will afford a so far reliable insight into the diseased mind. I have already, in a number of cases of that nature, had the behaviour of patients accurately tested by making them add up one continuous column of single figures, and by other simple experiments of the same kind. These methods, the particulars of which I cannot go into more minutely here, have the great advantage that they yield results by which any wilful dissimulation becomes at once distinctly recognisable. Experiments to this end have proved that it is quite impossible, even for those who are accurately acquainted with the governing laws in this department, to wilfully counterfeit the particular morbid disturbances here presented. In the way indicated we have tried to form an opinion as to how far the complaints of our patient are justified with regard to the diminution of his capacity for work, and it has been shown by this means that as a fact he possesses an exceedingly small capacity for mental work as well as an undoubtedly morbid increase of liability to fatigue. It should scarcely be difficult to apply tests of this kind to other departments of mental action, especially as to capacity of comprehension and attention, as to skill, power of recovery, divertibility, and so on. As, in investigations of that kind, wilful deception always betrays itself through deficient agreement of the results one with another and with other experi- ences, they present throughout the possibility of attaining to entirely assured results. I can tell you very little with certainty as to the probable further development of our case, but the patient's age is not favourable to a rapid adjustment of the disturbances. It is, however, possible that with a happy settlement ol the question of compensation, and with the removal of causes having real foundation, a material improvement and even cure will make its appearance.* Certainly many of these cases take a very obstinate course. The treatment for the moment can only consist in recommending industrious occupation. In addition, there is hypnotism to be considered, which often exercises a beneficial and soothing effect. We have employed it a few * The condition of the patient has distinctly improved in the last six and a half years, after a satisfactory solution of the question of compensa- tion, though a certain reduction of ability and of self-control persists. Insanity after Injuries to the Head 269 times on our patient with moderate results, but expect little lasting improvement from it, as his chief anxiety is not yet removed. The fact that traumatic neurosis, or, as I might rather call it, " fright neurosis," is recognised as being of psychical origin, has brought it into such close relationship with hysteria that, following the example of Charcot, cases of that kind are often allocated to that disease without due consideration. In this way one starts with the idea that the latent hysteria would to a certain degree be brought to light through the accident. No doubt hysterical disturbances can be set free through accidents. Yet it seems to me the picture of disease just now developed so essentially deviates from hysteria in its mode of origin, clinical expression, and course, that I cannot hold that simply to mix the two would be an advantage. Rather am I convinced that a more accurate knowledge of disturbances set free in a psychical way, as well as a more accurate knowledge of real hysteria — which latter is characterized by a permanent inclination to psychogenic symp- toms of various kinds — will lead us to distinguish from it a number of more or less analogous forms in which the origination of the morbid changes would probably take place in an essen- tially different way from that which we see in hysteria. LECTURE XXVII IRREPRESSIBLE IDEAS AND IRRESISTIBLE FEARS Gentlemen, — With the lecture on hysteria we entered on a department of morbid mental states in which the -peculiar disposition of the personality must be considered the real founda- tion of the malady. We had not to deal with an actual course of disease, but rather with a congenital and permanent change in the psychical attitude, affording a favourable soil for the development of a number of incidents of various kinds. Every possible degree of transition exists between hysterical predis- position and other forms of morbid personality — of " permanent psychopathic inferiority," as Koch has called it. We will now make a closer examination of a few examples of these conditions. First you see a schoolmaster, aged thirty-one, who came to the hospital of his own accord four weeks ago in order to be treated here. Except for a low forehead, slight inequality of the pupils, and exaggerated knee-jerks, this slender, lankily- built man presents no physical disturbances worth mentioning, yet his pulse has risen to 120 beats during the examination, a sign of great emotional excitability. The patient was, in fact, violently agitated when he had to come here, sank down on his bed, and said that the discussion in the hospital would cost him his life. He begged to be allowed to sit in the hall before the lecture began, so that he could see the audience come in gradu- ally, as he could not face a number of people so suddenly. The patient is quite collected, clear, and well-ordered in his statements. He says that one of his sisters suffers in the same way as himself. He traces the beginning of his illness back to about eleven years ago. Being a very clever lad, he be- came a schoolmaster, and had to do a great deal of mental work to qualify. Gradually he began to fear that he had 270 Irrepressible Ideas and Irresistible Fears 271 a serious disease, and was going to die of heart apoplexy. All the assurances and examinations of his doctor could not convince him. For this reason he suddenly left his appoint- ment and went home one day, seven years ago, being afraid that he would die shortly. After this he consulted every possible doctor, and took long holidays repeatedly, always recovering a little, but invariably finding that his fears returned speedily. These were gradually reinforced by the fear of gather- ings of people. He was also unable to cross large squares or go through wide streets by himself. He avoided using the railway for fear of collisions and derailments, and he would not travel in a boat lest it might capsize. He was seized with appre- hension on bridges and when skating, and at last the appre- hension of apprehension itself caused palpitations and oppres- sion on all sorts of occasions. He did not improve after his marriage three years ago. He was domesticated, good-natured, and manageable, only " too soft." On the way here, when he had finally made up his mind to place himself in our hands, he trembled with deadly fear. The patient describes himself as a chicken-hearted fellow, who, in spite of good mental ability, has always been afraid of all sorts of diseases — consumption, heart apoplexy, and the like. He knows that these anxieties are morbid, yet cannot free him- self from them. This apprehensiveness came out in a very marked way while he was under observation in the hospital. He worried about every remedy, whether it was baths, packs, or medicine, being afraid it would be too strong for him, and have a weakening effect. He always wished to have a warder within call in case he got agitated. The sight of other patients disturbed him greatly, and when he went for a walk in the garden with the door shut he was tormented by the fear of not being able to get out of it in case anything happened. At last he would hardly venture in front of the house, and always had to have the door open behind him so that he could take refuge indoors in case of necessity. He begged to have a little bottle of " blue electricity " that he had brought with him to give him confidence. Sometimes he was seized with violent palpitation of the heart while he was sitting down. Some little acne spots gave him so much alarm that he could neither go for a walk nor sleep. It struck him that his look had got very gloomy, and he thought it was the beginning of a mental 272 Lectures on Clinical Psychiatry disturbance which would certainly seize upon him while he was here. Many of the features of this clinical history recall hysteria, particularly the changing fears of disease awakened by acci- dental impressions. But the physical symptoms which accom- pany hysteria are wanting, and real apprehension, not only of disease, but also of all kinds of dangers, is the predominant feature, while the peculiar pleasure in being a sufferer which we often see so clearly in hysteria is entirely absent. Then there is a great uniformity in the moibid appearances. We may therefore count this case among the group of cases related to hysterical insanity, but pretty clearly distinguished from it, which we include under the name of the insanity of irre- pressible ideas. The appearance of uncontrollable fears, not to be overcome by the arguments of reason, which have brought our patient's actions under their yoke to a large extent, is diag- nostic of this ver3- common form of morbid disposition. Our patient knows quite well that nothing bad can happen to him in front of the hospital, but the apprehension which springs up in him is stronger than all reflection, and can only be kept within bounds by the knowledge that the door is standing open, whatever may happen, or that he can have recourse to his " blue electricity." The circle of these fears, which in this case includes apprehension of squares, bridges, crowds, railways, etc., may be quite different in accordance with personal tendencies and experience. In other patients we see apprehension of dirt, poison, needles, storms, clothes, and many other varieties. The whole course of the present case shows that the disease is deeply rooted in the general personality. It usually develops early in adult life, and lasts with greater or less fluctuations throughout the whole of life. In the most severe cases the symptoms may advance until mental freedom is entirely de- stroyed. The patients are then so much taken up with their uncontrollable anxieties that their whole thought, feeling, and action is ruled by them. But it is still generally possible to bring about a certain improvement in the symptoms by en- couragement and other kinds of psychical treatment. We have tried hypnotism in the present case, and, as is usual with patients of this kind, it has an immediate but only temporary effect. While the patient felt much relieved after the first few seances, his fears attached themselves only too readily to the new treat- Irrepressible Ideas and Irresistible Fears 273 ment. He was convinced that it did him no good, and soon lost the faith which forms the basis of the cure. "We will now try by methodical practice to accustom the patient more and more to go about freely outside the hospital, and so to overcome his manifold morbid fears. It is true that we cannot expect very much from this. Long-continued residence in one of the asylums for nervous cases suggested by Mobius, with plenty of opportunities for regular work under constant medical guidance and supervision, would be very useful to patients of this class. A longer stay in the hospital, with its very different objects and means of treatment, can hardly do the patient much good.* The case of an acrobat, aged thirty-five, will serve to show you the symptoms of irresistible fears in a rather different light. He was brought here yesterday by the police, to whom he had applied for protection when, having suddenly become appre- hensive on a railway journey, he had left the train, and was wandering aimlessly about in the town. As you will see, the patient is quite collected and clear, and gives connected information as to his experiences. We learn from him that nine months ago he fell 20 feet from a trapeze, on which he was performing, happily escaping with only a frac- ture of a metacarpal bone. But he fell on the back of his head, on which two non-adherent scars are visible even now. After the accident, he was unconscious for a long time. The third day after that an attack of convulsions was said to have occurred, which, however, was not repeated. Since his fall the patient suffers from apprehensive fears of a peculiar nature. As he relates it, the apprehension comes on, with violent oppression of the head, that he may, perhaps, blurt out indiscreet remarks, particularly lese majeste, especially if he finds himself in a large company of people, although it is altogether contrary to his sentiments. Sometimes the apprehension becomes so great that he holds his pocket-handkerchief before his mouth so as not to speak, but yet he has never said anything really punishable. During the last year he has, from preference, performed abroad. * We sent the patient back to his family after seven weeks, as constant occupation with plans of cure and the want of regulated employment had a decidedly bad effect. He has now been atyl^rk again for eight years, and his health is ' satisfactory.' His sister has in the meantime been treated by us for precisely similar disturbances. 18 274 Lectures on Clinical Psychiatry where he had no fear of immediate arrest for an offence against the Emperor. Further, on closing an envelope, he had the fear regularly that he must spit into it, and for this reason left his letters to be closed by others. On the journey from Heidelberg to the South, where he was expected, he became ill ; he lost con- sciousness, and, according to the statements of his fellow- travellers, also had convulsions. Then he was seized with great apprehension, and, fearing lest he should be arrested, got out and made for the river. The patient has very little informa- tion to give about this last occurrence, and, except for a rather depressed mood, presents no other psychical disturbance. Physically there is to be noticed a slight acceleration of pulse, and increased activity of the excitability of muscle, as well as of skin and tendon reflexes, also hyperaesthesia of the skin, especially under the stimulus of cold ; the knee-jerk is much stronger on the left side than on the right. f. In this patient, too, the fears might seem to have taken the form of impulses, but on closer examination we shall see that the patient does not really feel driven to the actions he fears, but that it is only the apprehension that he may, perhaps, do something of the kind which comes over him. The condition, therefore, differs from that observed in our first patient only in the fact that, in that case, the supposed danger threatened from without, while here it is expected to arise from the patient's own action. There are also cases, though fortunately they are not very common, in which we have to deal with actual morbid impulses to what, under some circumstances, may be extremely dangerous actions. In these cases the action is not feared, but is an object of pursuit, and the resistance to its being carried out arises not so much from feeling as from reflection ; if the obstacles are once overcome, the action is followed at first by a certain sense of satisfaction. But our present patient never goes to the length of carrying out the actions he fears, and the possibilities which arise in his mind are always such as seem particularly repulsive or alarming to him, while irt real morbid impulses the end seems desirable, however much rational con- sideration may be opposed to it. The clinical interpretation of this case of disease presents no very great difficulty. The convulsive attacks, which appeared soon after the accident, and apparently were repeated a short time ago, might be regarded as signs of epilepsy. But the Irrepressible Ideas and Irresistible Fears 275 morbid fears themselves, the hyperjesthesia of the skin, the fact that the attacks passed off without causing injuries or tongue- biting, their close connection with the states of apprehension, and the absence of other signs of epilepsy, suggest that we have rather to deal with a psychogenic picture of disease, of which we may attribute the appearances partly to hysteria. The peciiliar fears, however, are not actually diagnostic of hysteria, but the}^ belong to a nearly related picture of disease — the in- sanity of irrepressible ideas, etc. This is also a form in which degeneration finds expression, and for that reason we fairly often meet with cases in which the phenomena of these two affections, and also of maniacal- depressive insanity, which springs from the same root, are combined with each other in the most various ways. This interpretation of the case will prevent our attributing too much importance to the part the fall has played in pro- ducing the present disturbances. Even if the states of psychical weakness following on injuries to the head, which are totally different from what we have here, are left quite out of considera- tion, fright neurosis itself presents an essentially different picture from that which we see in our patient. Instead of a general hindrance to physical and mental efficiency and an increased liability to fatigue, we meet with signs of illness here, which are often enough observed even where there has been no previous injury to the head. We may, therefore, conclude that, in the present case, the accident is not to be regarded as the real cause of the disease, but only as the occasion setting free its symptoms, of which the ultimate foundation is formed by the peculiar dis- position of the patient. This conception is of great importance to our estimate of the future prospects of the case. While in the more severe forms of fright psychosis the disturbances only slowly, and in some circumstances never, pass away, we know that hysterical symptoms, though sharply defined as a rule, are usually extremely susceptible to influence and subject to change. Even when of very long standing, under some psychical in- fluence, they may disappear as suddenly as they arose. We shall, therefore, be able to count in our present case on producing a certain improvement by suitable psychical treatment. But as we are only able to remove the symptoms and not the hysterical predisposition, we must be prepared for the reappearance of much the same symptoms sooner or later, with or without an external 18—2 276 Lectures on Clinical Psychiatry cause.* This is more especially true of the irresistible fears, which do not come within the picture of hysteria, and show a great tendency to persist, A young lady, aged twenty-six, brought here by her relations three weeks ago, may also contribute to your knowledge of irrepressible ideas, though in an entirely different way. The slightly-built, ill-nourished, sickly-looking girl has an expression of pain and trouble. Her hands and fingers are always in slight movement, reflecting her mental restlessness. She is quite collected and clear, but only gives monosyllabic answers. Her maternal uncle is insane. She was constitutionally healthy herself, lively, and cheerful, but fell ill ten years ago of chronic inflammation of the tarsal joint, which brought her under medical treatment for a year. Even now walking is made diffi- cult and slightly painful by the stiffness of the joint. In answer to our questions, the patient says that she is not insane, but only a wicked person who would be sent to the devil if people knew how continually she sins. She does not deserve to be well treated, and she cannot bear that people should look on her as an invalid, when in reality she is only pretending. It is impossible to get any details from her, as she evades every attempt to extract information. We can only learn that she has been to confession unworthily, and so could find no rest, even if she went to the end of the world. She must go away, anywhere, only not to her home, where she has lied and deceived. She cannot stay here either, as people are far too good to her. So far as we know, this state of depression has developed quite gradually in the last year or two. It struck the patient's rela- tions that her mood changed quickly and abruptly. She occa- sionally expressed religious doubts, on account of which she was sent to the priest, and also to a place of pilgrimage. But this only produced an aggravation ot her condition each time. The restlessness increased, and the patient's sleep and appetite became worse and worse- her strength gradually becoming very much reduced in consequence. She felt burdened with grievous sins, of which she could not properly repent, and so was fallen into the power of the devil. She had neither wishes nor will ; everything had become indifferent to her. Her whole * We submitted the patient to a hypnotic treatment, which succeeded very easily, and removed all his complaints at once. Unfortunately, we could only keep him under observation for one week longer. Irrepressible Ideas and Irresistible Fears 277 previous life, with all her transgressions, stood out clearly before her, so that she was surprised at her own memory. She could not help brooding and having unclean thoughts, which broke her heart. Hence she worked feverishly, just to avoid thinking, although everything was very difficult for her. After great reluctance, she has informed me of the purport of her tormenting thoughts. She was almost continually haunted by ideas associated with the reproductive organs of the opposite sex, which need not be detailed here. Thoughts of this kind, concerned in different ways with the same object, persecute her unceasingly without her being able to ignore them. Hence she says that she must really wish to have such thoughts ; she must find pleasure in them, or they would not come. It is very difficult to divert the patient's mind from her painful self-torture ; she always returns to it. She is quite unable to read, or to occupy herself mentally in any other way, as these sexual ideas attach themselves, by the most remarkable connections, to her course of thought, however remote it may be. In her general thinking the patient is clumsy and slow. She has always to overcome great disinclination, even when she has to write a simple letter. She generally obeys the doctor's orders, but has a number of peculiarities. The baths give her pains ; meat is not good for her ; she must follow certain paths in her whole way of life if she is not to grow worse. No physical disturbances have appeared except stiffness, swelling, and pain in the left instep, and a tendency to constipation, which has existed for many years. She sleeps badly. In our last patient we had to deal with apprehensive fears of various kinds. Here we have a definite group of painful ideas, sometimes combined with impulses, which force them- selves on the patient. Here, too, we may assume that the dis- agreeable thoughts spring up against the patient's will, and are not intentionally harboured by her. Even though she says herself that she really wishes to think about such things, and so is responsible, it is clear that she has a strong desire to be freed from her tormenting thoughts, but cannot refrain from them. There is, therefore, an unmistakable similarity in the sjmiptoms of disease in the two cases, which appears even more clearly in the hypochondriacal fears connected with the medical treat- ment. On the other hand, we cannot overlook the difference in the general clinical behaviour of the two patients. First 27 B Lectures on Clinical Psychiatry- there is the short but rapid development of the picture of disease in this case contrasting with the very uniform condition showing but sHght fluctuations in the other. Secondly, there is the great inward restlessness of our present patient, and the serious effect on her general physical condition. Finally, there is the diffi- culty of thought, as well as the deep emotional agitation, contrasting in the strangest way with the feeling of inward apathy. I think it is clear from all these signs that there is not a per- manent condition here, as there was in the case of the first patient, but only an incident of a disease, which we may accordingly expect to pass off after completing its cycle. We cannot draw this conclusion from the purport and form of the irrepressible ideas themselves. Indeed, they might appear in just the same way as the expression of a permanent " psychopathic inferiority " depending on a morbid disposition. But it is the clinical accom- panying phenomena which oblige us to interpret the picture differently. I think that you have before you another of the many illustrations of the aphorism that a single sjonptom, however characteristic it may be, never justifies a definite diagnosis by itself, and that only the whole picture can ever be decisive of the clinical hypothesis. Now, however, we have to answer the question as to the inci- dent of disease to which our case belongs. According to the views advanced in these lectures, we will have to think more especially of the possibility of dementia praecox or maniacal- depressive insanity. The choice will not be very difficult. States of emotional depression, with self-accusations of sin and irrepressible ideas, may come under observation in both diseases. But the difficulty of thought, the great emotional excitement, which broke out in the most violent way when the patient was visited by her mother, and the absence of all eccen- tricities and negativistic features, make it extremely probable that we have an attack of maniacal-depressive insanity before us. Cases of this kind, accompanied by vivid irrepressible ideas, and generally having a very protracted course, are, in fact, far from uncommon. They are characterized by a somewhat rapid onset, without any premonitory symptoms of long dura- tion, and by the great emotional depression, the hindrance of thought and volition, and the ideas of sin by which they are accompanied. We may, therefore, expect that, in our patient's Irrepressible Ideas and Irresistible Fears 279 case, the symptoms which are so urgent and important at present will disappear entirely within a reasonable time.* But we must be prepared for the recurrence, sooner or later, of attacks which may either be similar to this or different. Of course, the clinical interpretation of the picture decides the treatment to be adopted. In contrast to the first case, asylum treatment, removal from the family, supervision to prevent the danger of suicide, rest in bed, and the most scrupulous care to secure proper nutrition and sleep are indicated here. We may also think of administering sedative remedies. I think a com- bination of moderate doses of opium and bromides appropriate. * When it had lasted between three and four years, the patient's illness ended in a complete cure, which still continues, nine years later. Its further course fully confirmed the hypothesis we formed from the patient's clinical history and condition. LECTURE XXVIII CONGENITAL STATES OF DISEASE Gentlemen, — In the course of heredity the disposition of the individual is determined by influences of very different kinds. On the one hand, we see the personal qualities of the progenitors, whether they be good or bad, healthy or morbid, reappearing in their children ; while on the other, the individual characters of posterity are guided in their special paths by the most various causes ; so that, side by side with the resemblance be- tween parents and offspring numerous variations are always developed. The general result may be either an advance towards perfection or the deterioration — the ' degeneration ' — of the stock.' In the latter case, when the morbid and pernicious influences prevail, the new generation will bear within it the seeds of destruction, which will certainly develop unless, in the further history of the family, some compensation for the degeneration or some diminution of the unsuitable peculiarities is acquired by the admixture of sounder blood. The clinical forms in which degeneration is expressed are extremely numerous. We know that it affords a favourable soil for the growth of the most different varieties of mental disease, and we also know that a number of psychical disturbances, especially maniacal-depressive insanity, hysteria, and the insanity of irrepressible ideas, etc., depend, more than any others, on morbid predisposition. Some- times the degeneration is seen in a permanently vitiated direc- tion of all the appetites and desires, from youth onwards, some- times the morbid features are evolved in the course of life, or vary in strength at different times. Hence we may, perhaps, discriminate between congenital states of disease and morbid personalities, according as the disturbances are apparently the expression of the morbid conditions of past generations, or seem 280 Congenital States of Disease 281 to be purely personal abnormalities, although it is certainly impossible to make any sharp distinction. If you wish to cast a glance of inquiry into this extensive province, I would beg you first to turn your attention to the case of a chemist, aged twenty-two, who was lately sent here by the police to have his mental condition reported on. He is charged with immoral behaviour towards a number of boys of the ages of ten to fourteen and a half. He generally spoke to them in the street, and, after sending them on some trifling errand, took them with him to his room, where he carefully closed the shutters 9,nd the door. After talking to them unobjectionably for a little while, he began to draw them to him and to commit the offences complained of. Finally, he gave them a present, and told them to hold their tongues, and to come back in a few days. In a letter he sent to one of the boys, while he was in prison before his trial, he begged for his forgiveness, declared that he was " so fond of him," and greeted him, " from his heart, with a kiss." The peculiar circumstances of the case led to an inquiry into the previous history of the accused. His father is described as very easily angered, a little brother died of convulsions, and a sister was " nervous." His mother had strong emotions to endure at the time of her pregnancy, and parturition was diffi- cult. The child was very delicate, and did not begin to speak so that he could be understood until he was four years old. Later on he often inverted the syllables of a word, saying, for instance, " Ungzeit " for " Zeitung." He suffered from head- aches, and was very timid and shy. His imperfect speech and small power of comprehension prevented his making progress in the State school, so he was educated at a private school. He changed from school to school repeatedly, had great quarrels with the masters, and wasted much of his time in rowing and sailing. He had great difficulty in passing the examination which would entitle him to volunteer. He wished to enter the army, but was rejected on account of a deformity of the right hand. He then studied at a polytechnic, where he spent a very great deal of money, pretended that he was a count, and tried to commit suicide when the deceit was discovered. Attempts to get him a place in a factory failed, as he was not seen at work for days and weeks together, but was always asking for money. Next he travelled to Bremen, in order to emigrate to America, 282 Lectures on Clinical Psychiatry posed as a doctor of chemistry there, and missed the boat. When he came home he was very irritable, and wrote to his parents, demanding large sums of money to carry out his plans for the future, but did not describe them in detail. He wrote of " a voice, which no one hears," of "an inward craving for something I cannot grasp, which yet compels the belief and the hope of satisfying soul and spirit if it is divined and appre- hended." He said he would find pleasure in struggling with dangerous but important experiments — air - ships, perhaps — for the desire of an occupation requiring a certain amount of daring was in his blood. He had only been partly to blame for his failures ; his teachers did not know how to deal with a pupil who was " cast in a special mould." His parents had noticed for some years that the patient was fond of the society of younger boys, and gave them unreasonably valuable presents. He used now to climb up a tree in the garden, almost every day, armed with an opera-glass, and watch the boys going home from the school opposite. He repeatedly tried to make the acquaintance of some of them, brought them into his father's garden, and went for walks with them. In these circumstances some written sketches, which accidentally fell into his father's hands, caused great anxiety, as they were of a highly morbid and objectionable character, and imaginary immoral experiences were described in them with painful accuracy of detail. There was also a comprehensive list of country houses and palaces in every part of Europe and America, with an exact account of the numerous staff of servants, from the " major-domo " downwards, and of the horses, rowing- boats, sailing-boats, etc. The value of the whole amounted to 41,380,000 marks, to which were to be added properties and manufactories to the value of 15,000,000 marks, a private bank with five branches, and ocean steamers and large yachts to the value of 12,821,000 marks. In an appendix was the descrip- tion of a summons to Kiel, on a secret mission for the Emperor, ending with the patient's appointment to the Navy, his pro- motion in two years to the rank of commander, and his invest- ment with " a very appreciative Order." The finding of these writings led his father to consult an alienist, and the patient was induced, much against his will, to enter our hospital, but took advantage of the carelessness of one of the warders to make his escape a few days later. As he Congenital States of Disease 283 begged very hard for forgiveness, and promised everything he was asked, his father tried once more to get him to study chemistry. Two months had scarcely passed when he was arrested for the offences against moraUty. The patient is quiet, collected, and clear. He gives a con- nected account of his life, though he often hesitates and comes to a stop, or breaks off suddenly. There is no disturbance of memory to be found ; his mood is indifferent ; now and then an embarrassed smile may be seen. On the whole, his behaviour is natural, though perhaps a little too amiable and affectionate. He frankly admits his crime, and explains it by saying that he had always treated his companions with warmth and affection, and thus the " evil side of his passion " had developed until finally it drove him, in spite of all his struggles, to forget the misery of his hitherto unsuccessful life in sensual pleasures. He was led into onanism by bad example when he was a little boy, and had also played with his comrades once or twice in an indecent way, but afterwards he never thought about such things ; he was far more occupied with thoughts of a girl, who was related to him, whom he would still like to marry. He began the habit of intercourse with women at Berlin, but lost his taste for it after getting to know a boy of thirteen, who attracted him very much. It was only recently that the gradually in- creasing impulse grew so strong that he committed his criminal offences, without being troubled by the detestable nature of his actions. He cannot understand how he can have done them, and feels a horror now of his behaviour. He has never had similar relations with grown men, nor felt sexual excitement at the ill-treatment of others, nor a taste for women's clothes or work. What he wrote was simply the creation of his imagina- tion, without any foundation in reality ; he only described it all as he did because it gave him pleasure, and it would be absolute madness to think of carrying it out. He ought not to be shut up in an asylum now, for he evidently sinned in an attack of " momentary moral insanity," and has come back to his senses since then ; he might be allowed to take part in a dangerous expedition to distant lands. A voice within, that cannot be eradicated, cries to him, " Per aspera ad astra." The patient's physical examination shows a powerful frame and well-developed muscles, slight inequality of the pupils, a trifling degree of phimosis and epispadias, slight shortening of 284 Lectures on Clinical Psychiatry the phalanges of the right hand, and traces of a union of the second and third fingers, which has been operated on at some former time. He has very thick lips and a rather husky falsetto voice. No other abnormalities can be seen. Of the noteworthy features of the picture described, the first are the strangely unsettled life the patient has led, his inability to accommodate himself to the national system of education and satisfy its demands, and the repeated change of the object aimed at, both at school and in later life. Such difficulties point to a considerable deviation from the average, chiefly in the direction of degeneracy, of which the traces are clearly enough seen, both in the physical deformities and in the delay of mental evolution. The patient's sexual failings should undoubtedly be taken in the same sense. We have learned, from often- recurring experience, that sexual impulses may be very early awakened in degenerates, that they often lead to onanism, and that from such a beginning they only too readily take the most extraordinary directions. Their course is often determined by accidental personal experiences, and in this way sexual desire may be directed towards persons of the same sex or towards children. Moreover, the sexual appetite, perhaps, in connec- tion with the remains of primeval tendencies going back to the animal period of our history, may be associated with the prac- tice or the endurance of ill-treatment, the so-called sadistic and masochistic aberrations. Lastly, sexual excitement may be so strongly aroused by special circumstances accompanying the sexual act — certain parts of the body, pieces of clothing, kinds of cloth or scent — that in the end it can only be awakened by them, and not by their natural incentives. This is fetishism. In the present case, it was apparently the patient's acquaint- ance with a boy who was particularly attractive to him that decided the further development of his sexual impulses, so that from that time he found a very special satisfaction in inter- course with boys. Indications of sadistic tendencies appeared in his written sketches. It was formerly supposed that the appetite for the same sex depended on a discrepancy between sexual disposition and physical structure. This assumption is contradicted by the numerous cases where, as in that which is now before you, there is an alternation of homosexual with heterosexual inclinations. Again, we see that, in degenerates, accidental influences, acting on an early awakened sexual im- Congenital States of Disease 285 pulse of natural or homosexual character, may give rise to such diverse aberrations, that this explanation altogether fails. In the vast majority of cases we may consider the foundation of the sexual aberrations to be the morbid instability of the natural impulse and its liability to disturbance by external influences. This is often a characteristic of other impulses, too, in de- generates. The patient's propensity to describe unreal situations in life, and give them the colouring of his wishes and hopes, is a striking feature of the case. When I met with this disturbance for the first time I was inclined to take these castles in the air to be the beginning of a paranoidal train of ideas, but now I am again uncertain if this is the right interpretation. In any case, we see once again reflected here the disagreement of thought and action with the reality, which is so common in degenerates, and is, perhaps, particularly favoured by their inadequate equipment for the battle of life and the over-activity of their impulses and imagination. But, while these considerations make it impos- sible for me to predict the development of paranoia in our patient, we can hardly hope that he will ever be able to win an independent position in life by regular work, while his un- natural sexual inclinations may sooner or later lead him to com- mit new offences.* We have yet another patient, who has been sent here to have his mental condition reported on, this time because he gave numerous orders to local shopkeepers, under all sorts of false pretences. This is the unsalaried University lecturer, who looks us up and down with such a deliberate air of inquiry. He repre- sented himself to be the head of an educational establishment, and referred his creditors to the profits from this undertaking, although he must have known that he would not be given per- mission to open a school. He also offered instruction to students in Latin, Greek, ancient history, French, English, Dutch, Italian, political economy, and the law. As the discovery of his * The patient has led a very unsteady life, and started many fresh scliemes, without carrying out any of them. He has changed his religion, and spent some time in a convent, and has been in several lunatic asylums. He has twice been on his trial for immoral offences, once against boys and once against a little girl, but was discharged as irresponsible on each occasion. Nothing has taken place to support the theory of a paranoidal affection. 286 Lectures on Clinical Psychiatry- previous history aroused suspicions of insanity, he was sent here for an expert opinion. It appears from the police report that the patient's father was a simple peasant, but it was decided to make the boy a scholar, because he showed signs of exceptional talent. He rose at once to the highest class in his elementary school and entered the high school as " primus omnium,'" to study theology and philology. He visited the Universities of Heidelberg, Munich, Utrecht, and Jena. He spent some time as a lecturer, and then went to Strasburg and passed the first examination in theology at the age of twenty-five. He is said to have been " like a raving madman "for a little while during an attack of typhus, which he had at Munich. It is reported from Strasburg that he forced his way, uninvited, into a meeting of the faculty of theology, and introduced himself as a future unsalaried lecturer. As a student he overworked himself, went without food that he might buy books, and led a very solitary life. After his appointment as a curate, his obstinate and self-satisfied disposition soon brought him into collision with his superiors. He changed his places at short intervals, wrote venomous articles in the newspapers, sent rude letters to the leader of the con- sistory, and was dismissed for insubordination. On the other hand, there are letters from clergymen, under whom he was curate, speaking in the highest terms of his hard work and excellent behaviour. Next, he found employment in a neigh- bouring country as a clergyman's locum tenens, but there, too, he wandered from one place to another, and finally gave up the clerical profession after he had been fined sixty marks for in- sulting the authorities. About this time he passed through a state of bewilderment, lasting several days, and remembered very imperfectly afterwards. He then found a place in a grammar school, but was soon on bad terms with the other masters. Next he taught as an assistant at Halle, where he passed the higher examination for teachers, but did not take a good place. He then went to Frankfurt-on-the-Main, where he gave private lessons, and there he was confined in a lunatic asylum for the first time, at the age of thirty-two. He had ordered a church to be unlocked for him, and began to preach, to try the acoustics, saying that the clergyman wished him to administer the Communion. He could only be removed by force, and gave the Freemason's cry for help. While in the asylum he was very Congenital States of Disease 287 exacting, irritable, and full of plans, and had no sense of illness. . Two months later he was admitted to another asylum. Here, too, the most prominent symptom was his exaggerated self- satisfaction, forming the very strongest contrast with his seedy and dejected external appearance. He was very loquacious, and fond of maintaining astonishing and exaggerated statements with great vivacity, and shouting down his opponents. He unfolded all sorts of plans, and wished to acquire the right of teaching as an unsalaried lecturer. He threatened to make good his claim to substantial damages for his unjustifiable detention. His condition often fluctuated in the further course of the malady, and at times his excitement rose to a high degree. He began to tear the blank pages out of books and write on them, passed flatus without restraint, robbed other patients of their food, filled his pockets with all kinds of things that did not belong to him, was rude and threatening, preached aloud to himself, chattered the whole night long, and made a confused and agitated impression. His weight, which had risen greatly at first, now quickly sank. Only after a year does a gradually progressive improvement seem to have set in. After eighteen months the patient escaped, but not before he had complained, in a number of petitions, of his deprivation of liberty. After having worked as a private tutor in several towns, but only for a short time in each, the patient married in his thirty- seventh year, and seems to have lived happily with his wife, who describes him as thrifty and sober. In the next few years he was once convicted of forgery, thrice of insulting the autho- rities, being condemned on the last of these occasions to one month's imprisonment, and once for unauthorized use of the title of doctor. Besides this, he was involved in a whole series of civil actions, brought against him by landlords and shop- keepers, because he lived in great style wherever he was, and never met his liabilities. In his numerous applications to the judicial and other authorities he takes a very high tone, threatens to make the authorities legally responsible for his misfortunes, and to obtain redress, questions the jurisdiction of the courts, and suggests the postponement of the day appointed for a hear- ing until a more convenient time. In a complaint, that his taxes are assessed too highly, he begs " the reigning prince " to inform him if a system of robbery, which " brings private people 288 Lectures on Clinical Psychiatry into conflict with the usurious laws," is legalized in his dominions, and actually goes on to demand " his rights " of the prince in a very confusedly- written petition. He insists, in long-winded statements, that the officials, " in violation of right and duty act in a way inconsistent with the honour of the country," and that the judgments passed " speak their scorn of all legal prece- dent," protests in a petition addressed directly to the Sovereign, " against the unqualifiable proceedings and the theories of govern- ment of a subordinate official," and sues for the punishment of his judges for the wrong done him, and of the revenue officers who made the distraint for disturbance of his domestic peace, threatening the latter with personal violence. When judgment was given against him, he always had recourse to every legal means remaining open, and in a matter of two marks he let his effects be distrained on, and himself be called on for an oath of manifestation, which, however, he had already taken. In court he behaved rudely and arrogantly, interrupted everyone, threatened to appeal to the press, banged the door, and had to be fined for contempt of court. He proposed to " balance " a charge of insulting the authorities against a petition he had presented for the punishment of the judge. On the other hand, he insisted that he had been very much excited for a long time, and therefore " full consciousness of the import of his expres- sions could not be ascribed to him "; there were reasons which " made his prosecution on a criminal charge impossible "; criminal proceedings could not be taken against him, nor, in case of his conviction, could the sentence be carried out. He made this plea, more especially, in an application to the imperial court of appeal and a petition for pardon addressed to the Emperor. In the meanwhile he was again charged with using the title of doctor without authorization. He declared, as before, that it had been conferred on him by the University of Philadelphia, and that he had lost the diploma. He behaved in a very excited way at the trial, talking a great deal in a vehement, arrogant, and often scornful tone, and interrupting the chairman and witnesses. When the police came to his house to break up the school he was carrying on in spite of the prohibition of the authorities, he fastened the door and made his boys sing comic songs while unsuccessful attempts were being made to break a way in. He shut his pupils up like prisoners. In his new place of residence he again became involved in numerous lawsuits, in Congenital States of Disease 289 the course of which he " put the patience of the judge who had to deal with him to the most severe test." As suspicions of mental disturbance had been aroused, he was examined by several experts, who came to very contradictory conclusions ; however, the proceedings taken against him were finally dropped. It is worth noticing that, at this time, he inferred from certain newspaper articles that his former con- sistory wished to be reconciled to him. He also regarded the transference of some patients fiom the asylum in which he had been confined to another, as a proof that confidence was no longer felt in its manager, whom he had violently attacked. The patient's restless, wandering life continued for the next few years. He tried to gain a footing in a number of towns, sometimes in schools and sometimes by giving private lessons. Doubts were repeatedly entertained of his mental responsibility on account of his insubordination and strange behaviour, which led to his being discharged from his situations, and, on one occasion, the intention of bringing proceedings against him to have him certified was only abandoned because he left the dis- trict. Wherever he went he very soon became involved in innumerable disputes. Eight years ago he was charged at one and the same time with fraud, extortion, the causing of bodily harm, unauthorized use of titles, resisting the police, and em- bezzlement, but was discharged on account of his doubtful mental condition. Three years ago he was again threatened with prosecution for fraud, theft, and unauthorized use of the titles of doctor and school director, besides a number of sum- monses. On his side he had made several charges of defamation, false witness from culpable carelessness, wilful perjury and sub- ornation of false witness, and had cast suspicion on judges and lawyers. This tim£, too, he was discharged on account of mental derangement, and began his old life again at once. When we let him tell his own story he expresses himself very well and clearly. Rather reserved at first, he soon warms to his ■subject, and talks with vehement gesticulations, ready wit, and great diffuseness. His tale owes its special colouring to his leaving out or softening down all that is unfavourable to him- self, while he lays the greatest stress on his own talents and •capacity. All his failures have been the result of the jealousy .and spite of ill-disposed or unintelligent men, sometimes of .simple ill-luck, but, above all, of his unjustifiable confinement in 19 290 Lectures on Clinical Psychiatry the asylum. Yet he found favour with eminent men, who were all ready to intervene at once on his behalf. The Prussian Minister of Education, to whom he had complained of the low place he was given in the examination for teachers, admitted to him that he had made a faux pas, and offered to have him paid six months' salary in compensation. His failure in the examina- tion depressed him very much, and an illness may have set in then, but his being sent to the asylum was a miserable intrigue. Several doctors assured him, while he was there, that he was perfectly sane, but the director detained him because he had once called him a scoundrel. One of these doctors was made director soon after, he says with a significant smile. He asserts that he subsequently collected a number of doctors' certificates declaring him to be sane. He takes his numerous misdeeds very lightly, and explains them in the most varied ways, showing that they were quite harmless and justifiable measures, to which he was driven by the hostile and concerted action of others. His statements are often inconsistent with the truth. He says that there are a great many lies in the reports, and that paper does not mind what you put down on it. The patient's mood is uniformly exalted. He speaks con- descendingly, with great self-confidence, and often with a sar- castic smile. He is free from all anxiety about his future, thinking that with the knowledge and ability he possesses he can never be at a loss. Even when the shipwreck of all his efforts is pointed out to him, it makes no impression whatever, and he thinks he could easily pay his very considerable debts if he were not hindered from working. He has absolutely no sense of his critical position, and only begs us not to say that he is dan- gerous. He has soon made himself at home in his new sur- roundings, behaves very unceremoniously, is always interrupt- ing everyone, and readily grows familiar. His great excitability showed itself when we were obliged to move him into another ward because he continued to talk to his wife from the window after he had been forbidden to do so by the magistrate. He immediately wrote furious complaints to the Attorney- General's office, to two of the Ministry, and to the Grand Duke's Privy Council. His physical examination has shown no results of any consequence other than very short sight, for which he wears a pair of gold spectacles, a slight scar on the left side of the forehead, bad and neglected teeth, and a striking develop- Congenital States of Disease 291 ment of the lower half of the face, with thick lips, powerful masseters, and a thick, fleshy tongue. The case before you has been diagnosed in very different ways. It has several times been regarded as one of a querulous delusion, but this opinion is easily shown to be incorrect. Except for the patient's failure to realize his illness, there can be absolutely no question of delusion here. The delusionary connection between the innumerable lawsuits is always absent ; they arise from various sources, and play no further part when once they have been settled in one way or another. Our patient has also been described as standing on the border between sanity and insanity, or again as suffering from chronic mania. According to this view, he passed through a maniacal state when he was in the lunatic asylum, which resulted, not in recovery, but in a permanently morbid condition. This assumption seems to me to come nearest to the truth. We can hardly doubt that his illness in the asylum was maniacal, as the description given of it is very characteristic. But while attacks of mania generally result either in recovery or in states of depression, we hear nothing about the latter here, apart from the depression after the examination for teachers ; neither has there been any re- covery. Indeed, from what we have been told about the patient's past, we must rather assume that after a few passing vacillations of the mental balance, a permanent condition of very slight maniacal excitement, perhaps with fluctuations in its severity, has developed as the result of the severe maniacal attack. This would explain the absence of consciousness of illness. Cases of this kind are not unknown, although they are not exactly common. The contrary has also been observed, and maniacal patients sometimes become quiet and unsociable in the intervals, which may last for years, between their acute attacks. This group, I think, may include the two apparently different forms of imperturbably cheerful temper and restless activity, and of perpetual despondency and discouragement, in which a surprisingly complete change from one mood to the other may occur. Maniacal- depressive illnesses in near rela- tions often throw light on these conditions. We may therefore assume that these slightly over-cheerful or unnaturally depressed moods form the morbidly altered soil in which more severe maniacal- depressive attacks develop. In this sense the term 19 — 2 292 Lectures on Clinical Psychiatry " chronic mania " might well be used, although I prefer the description " constitutional excitement," because I regard this condition, not as the unfortunate issue of an uncured mental disturbance, but as an expression of maniacal-depressive pre- disposition and a prelude to the characteristic form of that disease. Our patient's prolixity, the inaccuracy of his memory, his exalted mood and irritability, and the aimlessness and un- steadiness of life, which has caused him to make shipwreck in spite of his exceptional talents, all remind us strongly of hypo- maniacal conditions. His first illness, with its quickly-passing bewilderment, merits our special attention, as such a state is now and then introductory to the development of maniacal- depressive insanity. Until that illness, only his behaviour in Strasburg was suggestive of hypomania, while he had never given occasion for remark before, and seems, indeed, to have led a rather retired life. For the future, we must be prepared for the persistence of his present maniacal mood, but it is pos- sible that a violent attack may set in once more, and also, perhaps, a more or less marked condition of depression.* A complete contrast to this patient is presented by a railway employe, aged sixty-one, whom I should like to show you for the purpose of comparison. His sister was insane during preg' nancy, but recovered, and his son died at the age of seven of brain disease. The patient himself was always a quiet, hard-working, " punctual " man. He fell ill for the first time sixteen years ago, when there was an attempt to make him re- sponsible for the derailment of a carriage, and in addition to this he received notice to quit his house unexpectedly. There- upon he became apprehensive, could not do his work, and finally was sent to an asylum, from which he was discharged as cured after four years' residence. He then remained well for ten years, but fell ill again two years ago, after paying a visit to an insane woman who lived in his neighbourhood. He came home much excited, complained of pressure on his chest, apprehension and sleeplessness, ran about restlessly, could not remain long anywhere, and finally made a rather feeble attempt at suicide by giving himself a slight cut on the forehead with a wood- chopper in the presence of his wife. This led to his being brought to the hospital. When you look at the patient you are struck * The patient has continued his ill-regulated life, and has again come into collision with the criminal law. Congenital States of Disease 293 at once by the enormous size of his skull, enlarged in every diameter. The man is strongly built, and looks comparatively young and vigorous for his age. He is collected, quiet, and clear, and shows a very marked feeling of illness. He says he has no more pleasure in anything, cannot enjoy himself, and feels apprehension, which lies about his heart, and is worst in the morning. It plagues him day and night, and gives him no rest ; he cannot occupy himself steadily, because there is always the same struggle. It often seizes him so violently that he can- not help screaming, and he is always so frightened that he does not know how to help himself. Besides that, there are the bad thoughts that rise up in him which he cannot overcome. The patient really is unable to describe them in detail, but they are evidently thoughts of suicide. Twice he saw three-cornered stars before his eyes, and each time he felt an impulse to suicide ; it was like a voice within. There has never been such a disease before, and he certainly won't get well this time. He cannot stand noise ; music, too, is not for him. He cannot go to church either, he is so much upset by it. His limbs often twitch ; when he is lying down there is a shock, and his hands fly apart, his mouth opens, his head moves about. Rolling movements of the head, jerking open of the mouth, and spasmodic contractions of different groups of muscles have, in fact, been observed occasionally. His sleep is very bad, and is the subject of con- stant complaints, but he takes his food well, and his weight has slowly but steadily increased by 10 kilograms. This very uniform description of disease, which has shown only quite unimportant fluctuations since the patient's admis- sion, is difficult to fit into the frame of any of the forms of in- sanity known to us so far. It is plain that the patient's appre- hensive depression is merely an increase of a condition which has accompanied him all through his life. " I may say that I was born in apprehension," as he himself declared. The name we give to such a permanent disturbance of the attitude towards the attractions of life, in the form it takes as an expression of degeneration, is " constitutional depression." It must, how- ever, remain doubtful, for the present, if all the conditions thus comprehended form a single, uniform group. In some cases, well-marked insanity of irresistible fears is seen to develop on this basis, while in others the pusillanimity and absence of the joy of life lead simply to a progressive contraction of all its 294 Lectures on Clinical Psychiatry relations to the point of complete seclusion from the world. Finally, there is a large group of cases in which obvious fluctua- tions of the condition, it may be with sudden reversals of mood, point to a moie intimate connection with maniacal -depressive insanity. Here we will remember that attacks of periodical mania are known to arise, not very infrequently, from the soil of permanent morbid depression. Moreover, we may very well assume that, just as there are attacks of "periodical mania" arising on the basis of a permanently exalted mood, so their counterpart must also exist in the shape of attacks of more pro- nounced depression, as an increase of a constitutional and fimdamental condition of the like complexion. As a matter of fact, we do see such cases of " periodical depression " side by side with those of more or less pure periodical mania, and both may arise from the soil of a constitutional mood of morbid cheerfulness or depression. The picture of maniacal-depressive insanity is thus completed in its most delicate touches. How- ever, the conception put forward here is, for the present, only an attempt to arrive at a more complete comprehension of this disease as a certain form of morbid disposition. Further experience must show how far this point of view will prove correct. In the meanwhile you should make a note of the picture of periodical depression in our patient. The individual attacks are only imperfectly distinct from the permanent condition, chiefly, no doubt, because the latter exhibits a mood of the same colouring as they. We have also to notice all kinds of psychogenic disturbances and uncontrollable impulses, such as axe occasionally observed in maniacal -depressive insanity also, and point to the common origin of all these manifestations of degeneration. In all probability the patient's complaints will once more die away very gradually, without our being able to hope for any real recovery.* The treatment consists, in accord- ance with the severity of the symptoms, of care in an asylum, rest in bed, the administration of small doses of opium, mental diversion, and occupation. ♦ The patient was discharged improved, after spending two years in the asylum ; but many years later he was reported to be " still very ill." LECTURE XXIX MORBID PERSONALITIES Gentlemen, — It is often made a reproach against alienists, both in jest and in earnest, that they suppose that everyone is mad, and it is true that those who are occupied with the study of morbid mental conditions cannot help seeing that they have their deepest roots in processes met with in normal life. Wherever we try to mark out the frontier between mental health and disease, we find a neutral territory, in which the imperceptible change from the realm of normal mental life to that of obvious derangement takes place. The difficulty of making the distinction is particularly great when we have to deal with congenital abnormal conditions and not with actual incidents of disease, in which our decision is made easier for us by com- parison with the patient's behaviour when he was sane. The standard we use in recognising the morbid features of a man's mental life is his departure from the average in the direction of inefficiency. The fact that certain qualities have a very different value for the general purposes of life at different times and in different circumstances would alone prevent our coming to an invariable decision. We also see that the devia- tions from commonplace limits do not, of course, extend simul- taneously and to an equal distance on every side of mental life. Indeed, in the vast domain of morbid personalities result- ing from previously existing degeneration, we find every possible combination of inefficiency with healthy and even with excep- tionally gifted dispositions. This variety is all the greater than that of normal personalities, because the morbid deviations in kind and degree have a wider field over which to extend. But, for obvious reasons, only a part of the morbid personalities in existence come into the hands of the alienist, generally when the circumstances of a crime call for a judicial decision as to the 295 296 Lectures on Clinical Psychiatry mental condition of its perpetrator. Many are still able to fight out the struggle for existence well enough with the aid of their normal qualities, although they are distinguished from the average mass of mankind as oddities and striking personalities, while many come to ruin through their unpractical dispositions, and are treated with pity, contempt, or abhorrence, according to the course of events. The forms which morbid personality may take are so various that it would be an absolute impossibility to pass them all in review, but we may make ourselves acquainted, at least, with a few examples. First we will turn our attention to an engineer, aged thirty-three, who is stranded here for a little while after a most chequered career. A sister of the patient's mother and also one of her aunts were insane. The patient himself is said to have had teething convulsions in infancy, and later on to have fallen from a tree, and lain for some time insensible. From childhood he was unsociable and restless, and often stayed away or ran away from school. He was not without talent, and made good progress, especially in mathematics, drawing, and literature, only lacking perseverance. He could not get on anywhere, was insubordinate, played silly tricks, and consequently had to change the day-schools and boarding- schools to which he was sent several times. It also happened that, to escape the annoyance of school, he simply disappeared for weeks, to turn up again suddenly among relations living a long way off. Sexual development set in very soon, and the patient had to be treated for gonorrhoea before he left school. He also masturbated a great deal. He was operated on for phimosis, and suffered for a very long time from wetting his bed. At the age of twenty he entered the army to serve for one year, was several times punished for drunkenness and breaking leave, was imprisoned for insubordination, and, finally, was discharged from military service as " mentally defective." Efforts were now made to get him into different workshops and factories as an unsalaried pupil, but he was always dismissed in a short time on account of his tendency simply to leave his work undone, to drink, and to indulge in sexual debauchery. An attempt to send him to a technical school was equally un- fortunate. He got drunk in a disorderly house when he had no money, and wounded with a knife the man who was turning him out. He then lived for a time with relations or at home, and came Morbid Personalities 297 of age. Then one day he went away, " not being on very good terms with his father," but was caught again, and, at the age of twenty-four, was sent to a lunatic asylum for a short time. As he repeated his flight from home after his discharge, taking with him a considerable sum of money, which he quickly spent in disorderly houses, he was sent for three years to a large lunatic asylum. Here he occupied himself with music, languages, mathematics, and stenography, but was childishly unstable, and also insubordinate in his behaviour, played tricks on and abused his fellow-patients and the warders, made mischief everywhere, was presumptuous, overbearing, and unmanageable, had not the least understanding of his position, and often made all kinds of promises of improvement of his own accord, always speedily returning to his old vicious habits. After his discharge fresh attempts were made to get him a situation in one place or another, but always with the same result — that in a short time he made himself intolerable by his de- bauchery and collisions with the police. Again he wounded someone with a knife, and was tried and condemned. Yet he ultimately passed his examination as a mechanical engineer. He got into debt, and led a very free life. " There was a lot of devilry done, and I was in it," he said. He was turned out of one place for idleness and persistently frequenting disorderly houses, " with which he had already been acquainted," and was again handed over to an asyhim. He repeatedly got away, however, and led a vagabond life, gaining a bare living by pawning his things and playing the piano in public-houses. As soon as he earned anything he spent it on " going on the burst with women," and was eventually arrested and convicted of bilking. He escaped from an emissarj' of his father, who was to bring him home, and found a place again, but immediately let himself be tempted into fresh debauchery, and was once more imprisoned for bilking. The same thing happened to him yet again, when he had resumed his vagabond life. At last he found a refuge and some work in the family of some friends, but in spite of all his good resolutions he ran away again, got drunk without being able to pay, and was arrested and punished. As these outbursts increased in frequency, happening twice in the course of a few months, and as he had also been run over while he was drunk, he agreed, under pressure from his friends, to place himself under our care. 298 Lectures on Clinical Psychiatry The patient, who is quite clear and systematic, relates a great part of these experiences himself. His narrative is cleverly told, and his memory, apart from inaccuracies in dating the various sections of his intricate career, is excellent. He says that the statements sent from the asylums he formerly visited are very much exaggerated, but in other respects he shows no tendency to set his hfe in a particularly favourable light. On the contrary, it is a striking fact that he tells his story with a certain satisfaction, and feels rather a hero. There is abso- lutely no trace of shame or real repentance, and his promises for the future bear the stamp of mere phrases, which he uses to escape as soon as possible from irksome restraint and loss of hberty. " Cunning is stronger than force," he says sometimes. He has not the least comprehension of his incapacity to live in freedom which he has now shown on innumerable occasions. He says, without appreciating the meaning of these experiences in the least, that he can have no difficulty in getting on as soon as he gets work again. He has, in fact, got himself some pieces of work, which he has done so satisfactorily that he has been well paid for them. After having once made use of the free exit allowed him to bilk someone, he escaped repeatedly, each time in a slyer way, received the money he had earned, went on the burst in the town, played the piano in public-houses, and was eventually brought back again by the police. He gave as the reason of his escaping that he had received no definite assurance as to the form his immediate future was to take. He would have behaved unexceptionally if he had had the prospect of his dis- charge in a few weeks, or even months. There is nothing important to remark in the result of the physical examination except a slight inequality of the pupils. If you only look at the knowledge, memory, and natural manner of our patient, and the continuity of his course of thought — that is, at those features which first and most obviously come under consideration — you will hardly suppose that you have to deal with a morbid personality here. It is only when the whole life of the patient is reviewed, with his action and the position he takes up towards his own past, that the full extent of the disturbances is seen. Hence everyone who has had an opportunity of closely observing his ways has gradually come to the same conclusion. We evidently have to deal with an Morbid Personalities 299 instahility of the will existing from childhood, and resulting in the want of all perseverance and all resistance to temptation. It seems as if these motives which arise from moral feeling had not developed in the patient. He does not feel the unworthiness or even the disadvantage of his way of life, but recalls his adventures with a certain degree of satisfaction, and will not let his action be decided by consideration for his parents or for his own future, but only by his momentary appetites. With this short-sighted selfishness are associated an exag- gerated self-satisfaction, a complete want of sympathy with others, whom he likes to make the butts of his raillery, and occasional great irritability, which has repeatedly driven him, especially when under the influence of alcohol, to serious acts of violence. This last peculiarity would suggest an epileptic foundation for the malady, particularly as the patient has some- times led an orderly hfe for weeks together, and has twice had fainting-fits.* But the morbid want of self-control, which has made it im- possible for him to win a place in life corresponding to the talents he possesses, is not a symptom of epilepsy, but an evidence of degeneration. We may point out, however, that indications of epileptoid disturbances are not very uncommonly to be found in morbid personalities. Morbid incapacity for regular employment is even more strongly combined with exceptional aptitudes in the case of an actor, aged thirty, who was brought to us three weeks ago because he had swindled a prostitute of a diamond ring under an assumed name. He simply put it on his finger, and made an appointment with the girl for the next day at a fashionable hotel, where he was not to be found. On his arrest he declared that the hussy had given him the ring, and that he had sold it since. He made an attempt at suicide in the police cell, which the doctor did not think was seriously intended, and then was seized by attacks of excitement and convulsions, which led to his being brought to the hospital. The rather pale, ill-nourished, clean-shaven man, who is * The patient first spent some time in a large asylum, where at irregular intervals he exhibited attacks of irritable depression, always resembling what is seen in epileptics. Then, nearly three years ago, he went to America by arrangement with his parents, and earns his living there with a little help by playing the piano. 300 Lectures on Clinical Psychiatry dressed with a sort of shabby gentility, presents both in his out- ward appearance and in his whole air exactly the picture of an actor come down in the world. He talks much and very adroitly, makes use of pompous, high-flown phrases and all manner of professional expressions, and pours out a flood of most astounding disclosures from his life. He finished his school career at sixteen, and first went into the navy, then studied medicine at Chicago, and also at Strasburg and Leipzig, and took a degree in medicine at Wiirzburg. Next he became an actor, and was in succession a coachman, a waiter, a gold-digger in South Africa, and a street-sweeper in New York. There he got to know a Russian nobleman, who took him to his estate in Russia, where he learned the Russian lan- guage, and went as an interpreter to Teheran. But love of his art drove him on to the stage again. He played in Russia, and then came to Brussels, where he fell into want and became a porter. In this capacity he made the acquaintance of Coquelin, who engaged him for the Theatre Frangais, and took him with him on his great tour to the Far East. Afterwards he played in all the principal theatres, always in leading parts, and married a woman of good family, an angelically pure creature, who gave him four children, but they all died in infancy. In describing his unspeakably happy family life, the patient gets into a state ot the deepest emotion, laments his fate, and imagines how dreadful it would be if his old father and the mother he can never forget heard anything about his present position. The affair of the ring was a very harmless one. He only meant to show off a little with it, and never thought of keeping it, but was forced to sell it for want. For the rest, he is a respectable man who cannot be confronted with a girl like that — " a creature whose whole life is based on the highest power of erotic sallies." When we examine these fantastic statements more closely, of course we find the grossest contradictions. The patient admits this at once, and accounts for them by new and quite inconsistent stories, explaining that he has been obliged, by special considerations, to misrepresent many of the details. But the new statements also prove to be fictitious, and he will give you the most diverse descriptions of his life by the dozen, always assuring you, " on his word of honour," that he has really told the whole truth this time. We can easily understand the real reason for his inventions from the information the magis- Morbid Personalities 301 trate has given us. It has transpired that he is a swindler who has practised an endless series of almost incredible frauds for many years, under various names and in many different towns, and has always disappeared suddenly, leaving numerous debts behind him. He has been in prison several times. If we set these facts before him he is never at a loss for an excuse. Some he flatly denies, others he sets in quite a dif- ferent light, others, again, he admits with contrition, pleading the excuse of his destitute condition or other special circum- stances, and always insisting that in reality he is a perfect gentleman. The cleverness and volubility he evinces in these conversations are astounding, and, besides, he has a perfect mastery of the German, Russian, and French languages, and a fair acquaintance with English, Polish, Roumanian, Hungarian, Italian, and Swedish, and understands a little Latin, Greek, and Hebrew. He possesses a certain knowledge, superficial and defective, no doubt, of widely different subjects, and is trying since he has come here to acquire as much medical science as possible in conversation, bringing it out occasionally in a surprisingly matter-of-course way. He knows well how to dominate those around him, and to get himself privileges in all sorts of ways. He becomes confidential and officious the moment he is met in a friendly spirit. A series of " attacks " have been observed since he came here, in which, with loud groans and lamentations, the patient writhed, whined, and begged for morphine. He said that a number of eminent physicians, whom he named, had declared this drug to be indispensable. Finally, he threatened to commit suicide, and became rough and turbulent, but was tranquillized by being sprinkled with water. It appears that he has often had such attacks before, and has been in several lunatic asylums on that account ; one of his landlords said that he suffered from epilepsy. Once he was speechless for a time, and could not utter a sound, or understand what was said to him, but after- wards wrote on a piece of paper, " Disablement of the vocal cord." He cannot be induced to do any serious work, and only reads novels, smokes, talks, plays on the piano rather badly, but not without talent, recites, though, it must be confessed, only moderately well, studies those around him, and tries to amuse himself as best he can. It is doubtful if we should be justified in calling this extra- 302 Lectures on Clinical Psychiatry ordinary personality insane in the strict sense of the term. We have before us a born swindler, who, in spite of many talents, is entirely destitute of the essential requisites for work — perse- verance and a sense of duty. Hence his whole course of life bears the stamp of caprice and immorality. He is incapable of any regular occupation, never stays long anywhere, and is always craving for change.* His memory is remarkable, but it gives him evident pleasure to keep on astonishing his hearers with ever-fresh inventions. He has no sense at all of the worth- lessness of his conduct. Although he is apparently overcome with emotion at his own fictions, deep or lasting feeling is quite , unknown to him. The first place in his character is taken by per- sonal vanity, which urges him to fantastic boasting, to ruthless infliction of injury on his victims, and to senseless squandering of the money he procures, by swindling, theft, and fraud, with- out a qualm of conscience. If such a personahty is measured by the standard of a law-court, it is simply that of a criminal and a swindler. Yet the physician cannot escape from the con- viction that the patient has a congenital incapacity for a regular course of life, stronger than all education, experience, and self- control. At any rate, we come very near the limits of action of " morbid liars and swindlers" in the present case. This is more especially confirmed by the obviously hysterical features seen in our patient, even if we regard the " disablement of the vocal cord " as a wilful deception. And it is evidently not simple selfishness, but rather an uncontrollable impulse towards an adventurer's life, which always drives him from his situations, and makes him unable as well as unwilling to settle down any- where. He will certainly have to pay for the indulgence of his tastes in a very unpleasant way, for though the alienist may see in him a morbid personality, it is not probable that a judge will ever regard him as anything but a crafty and dangerous impostor.f * In some neurotics, neurasthenics, and borderland cases, but where the question of insanity, in the general or ordinary acceptation of the term, could not be entertained, I have observed this phenomenon for many years. In my own practice I have designated it Peripatetic Mania, and, in certain cases, it requires as careful watching as do the hallucinations of grandeur in the early stages of general paralysis of the insane, in order to protect the finances of the patients or their relatives. — Editor. t The patient was subsequently convicted and punished in Vienna. A few years later he made a determined attempt to gain admission to my house, saying he was ' Dr. B.,' and a colleague of mine Unfortunately, he was turned away before I could speak to him. Morbid Personalities 303 We meet with just the same difficulties in reporting on the case of a farmer, aged sixty-four, who has given full employ- ment to both magistrates and doctors for nearly twenty years. Again and again the question was raised whether they had to deal with a case of mental disease or with an ill-conditioned character, and the answer given has been different every time. The patient belongs to a very degenerate family. His father was insane, and ended his life by suicide, and one of his father's brothers was peculiar, very avaricious, and a general laughing- stock. His mother was temporarily insane, and died of a " stroke." One of his sisters was insane after a confinement, and a brother, who is feeble-minded, is in an asylum. Until his forty-second year the patient had only been convicted of a few unimportant offences, but at that time he came into possession of considerable means, inherited from his father, and then began a series of lawsuits, far too many to be enumer- ated here, which have left him completely ruined. The official reports we have seen, which cannot yet be considered complete, refer to 81 prosecutions on criminal charges, 41 informations laid by him against others, and no civil lawsuits. He was convicted in 65 of the criminal cases, but on most of these occasions he was only sentenced to small fines, as the offences which accumulated from his forty-fifth year onwards were, withoiit exception, very trivial. Generally there was a question of trespass. He drove over other people's land, ploughed beyond the limits of his own fields, let his cows graze on his neighbour's clover, and cut into his neighbour's hay in mowing. Several times he reaped the crops he had sold stand- ing, after having quarrelled with the buyer, and once, under similar circumstances, he tore up a field full of potatoes. A second group of offences consists of petty larceny and frauds. He appropriated articles that had been left unwatched, and used them himself, stole his neighbour's eggs under the pretext that his own fowls had laid astray, brought tools away with him when he was discharged from prison, and put several heavy chains into the balance when he sold his hay by weight. He was also guilty two or three times of signing other people's names to letters and petitions. He made a number of false and slanderous accusations, principally against the rural police- man, who had so often reported him, but also against all kinds of people with whom he happened to have quarrelled. He 304 Lectures on Clinical Psychiatry charged the witnesses who did not support him with perjury, a neighbour who had accused him of stealing grapes with forgery, and two other neighbours with arson, one of these having burnt a heap of rotten forage which the patient had dishonestly cut on his land. He accused his brother's guardian of defalcations, and one of his enemies of bribery, disorderly and indecent behaviour, and living with a mistress. In a single year he brought twenty- two charges of this kind, and fifteen times he repeated charges previously made, or appealed to the Public Prosecutor or the Ministry of Justice. He charged the burgo- master and the town clerk with indecent assault, declaring that they had made immoral advances to his wife in the town- hall. He also brought a charge of manslaughter against a neighbour, who, he said, had undoubtedly maltreated him in such a way as almost to cause his death. Two years earlier he had brought a charge of maltreating his wife in an exactly similar form. All of these numerous charges depended on witnesses who generally knew nothing about the affair, or else contradicted the accusation ; but in spite of the absence of any prospect of success, they were carried through all the courts of appeal. Sometimes they referred to events long past ; thus, the patient sued a tanner for 5 marks, the value of a calf-skin said to have been missing eight or ten years previously, accused him of perjury when he denied the debt, and left no legal pro- ceedings untried. In connection with these events, which show that he was at perpetual war with those around him, the patient was convicted on many occasions of grossly offensive conduct, of using threatening language, and of disturbance of domestic peace. He dirtied his neighbours' doorsteps in the night, smeared filth on the latches, posted up offensive notices, smashed the lock of a door, and threatened personal violence. Lastly, he broke the police regulations in every conceivable way. He was absent from fire-drill, fastened dirty tubes to the public foun- tain in order to fill up his barrel of liquid manure, fraudulently evaded the payment of tobacco dues and dog-tax, failed to make a return of the number of his labourers, opened a chalk-pit without permission, drove through the village in defiance of the bye-laws, and left his manure-cart standing in front of his neighbours' doors. The patient's appearances in court in connection with his Morbid Personalities 30^ civil obligations were almost as numerous and varied. His pecuniary relations to his brother in the asylum were a specially abundant source of trouble. Every attempt of his brother's guardians to compel him to perform his duties led to a long chain of actions, which were carried on with the greatest obsti- nacy, and always absorbed large sums of money. It was useless to make any agreement with the patient, as he never kept to it, but commenced fresh actions, or made it necessary to bring such against him. His butcher and baker, his doctor and chemist, were also obliged to sue him, for he refused to pay them on the most frivolous pretexts. He declined to pay for a cow, more than a year after he had bought her, on the ground that she had not been worth the money, although he had sold her again in the meanwhile, and had had a calf from her. These perpetual lawsuits, which often swallowed up a great part of the property in dispute, to say nothing of loss of time spent in writing out documents and attending at inquiries and on court days, led to the patient's continual impoverish- ment, until at last he was obliged to seek the poorhouse. His wife sought for a long time to restrain him from his senseless litigation, and finally tried to help him by artfully causing the remains of his property to be transferred to her. But eventually she became ill herself, apparently with a real queru- lous delusion, and then, either alone or in association with her husband, who followed her blindly, she began a fresh series of lawsuits on her own account, connected with the transference of the property, and carried them on with passionate eagerness, until they were brought to an end by her being certified as insane. Our patient himself had long been regarded by his neighbours as " very spiteful and litigious," a man who could never acquiesce in law and order, and cared for nothing but quarrelling and litigation. His wife said more than ten years ago that he was very nervous. He slept badly, got up at one or two o'clock every morning and cooked himself food, wandered about rest- lessly, bought things he could not use, and had spent about 6,000 marks unnecessarily. " When he does anything wrong he has no idea that he will be punished for it. When called upon to pay a fine, he seems very much upset. He cannot under- stand at all why he should be punished, and complains that he is persecuted by everyone." It was thought necessary to have 20 306 Lectures on Clinical Psychiatry him certified as insane, but the doctois called in could not agree. One declared that the patient was suffering from periodically- recurrent states of semi-consciousness, and another that he was not really ill, but cunning and artful. He himself alleged in one of his petitions, as an " important reason," that he was mentally irresponsible, and so could not be punished. He re- peated the plea of mental derangement so often, that he was ordered to be examined at this hospital seven yeais ago, when he had to be brought here by force. The police surgeon thought that he was unwilling to come because he was a malingerer and was afraid of being found out. The report on this examination left it an open question whether he was insane in the sense required by the criminal law or not, and he began his old disputes afresh. Now at last the determination to have him certified, which had again elicited a number of contradictory opinions, has led to his being once more under observation in our hospital. Our patient, an ill-nourished man of medium height, who looks very old for his years, has listened to our account of all this without any sign of real interest. His face is wrinkled, and his mouth is almost devoid of teeth. His large ears stand out far from his head, and the lobes are soldered. His right pupil is more dilated than the left, and his hearing is rather bad. The arteries in his arms and temples are corrugated and hard. These and a double inguinal hernia are the only physical changes ta be seen. The patient's sleep appears to be normal, and his weight has increased since he was here before. If we d'aw the patient himself into conversation, we find that he is collected, clear and methodical in his ideas, but he has to be pressed to answer our questions adequately. He seems to be listless and morose, and gives us brief, evasive, and indefinite replies, but gradually he begins to show more interest. We find that he has a very good recollection of his numerous appearances in court, and often defends himself in the very words- he used at the time. It is true that he repeatedly declares that he cannot remember anything about some particular occurrence, because his memory has grown so bad, saying, " Often when anything happens, I can't remember it properly," but it can generally be shown by a careful use of indirect questioning that he knows quite well what we are referring to. On the other hand, his knowledge of important public events, and of every- Morbid Personalities 307 thing lying outside the narrowest circle of a countryman's interests, is very small, and he has difficulty in doing arithmetic, although he generally finds the correct answers to the sums. He says that he voted at elections " as the parson arranged." He maintains that he became involved in his legal difficulties and came into collision with the police by no fault of his own. " I have never done anything wrong." It was always other people who were to blame. It was all " lies and nonsense "; the court was misinformed, and false accusations were brought against him. " What extraordinary things are said about one !" He does not know at all why he always got mixed up with such unlucky affairs ; people were unfriendly, and " one can't get one's rights." He really could not put up with being punished when he was not to blame ; but his complaints were rejected because the false witnesses always made everything seem different. Things were not properly inquired into, and the witnesses ware not put on their oath. "If the gentlemen of the court had gone themselves, it would have been different." He made all those accusations because he could not bear to see a wrong done, but sometimes he was inconsiderate. One is bound to believe people when what they have said has all been true before, or one would not be able to believe the parson in the pulpit, and one is bound to take notice of it when one hears of anything wrong. If he is driven into a corner, and shown the obvious falsehood of some of the charges, he sighs and says : " If only I could escape from this world — if only the Lord God would take me from my troubles !" People may believe what they like, and he would rather they put an end to him at once. All he wishes for now is that the Grand Duke would " try his cause "; he would be contented with his decision. He is not mad, but onl}' often low-spirited and depressed. He would like to have his house back, and then go on foot to Rome and Pales- tine. If he made it a plea that he was always represented as being insane, that was because a man must defend himself as best he can. Since the patient has been here he has not had much to do with those around him, and has talked and read very little of his own accord. He has often gazed from the window apathet- ically for hours together. Our patient's very grave heredity at once suggests the sus- picion that this is a case of morbid persoiiality; and the suspicion 20 — 2 308 Lectures on Clinical Psychiatry becomes a certainty when we consider the weakness of judg- ment with which he carried on the most hopeless and senseless litigation, the incapacity for learning better, which prevented any misfortune from teaching him wisdom, and the passionate obstinacy with which he xmdermined his own position. His whole behaviour reminds us very much, at first sight, of that of the victims of a querulous delusion. We find in our patient, who has never done anything wrong, and cannot bear to see wrong done, the same exaggerated self-appreciation, the same sensitiveness to the least encroachment, and the same inability to understand or respect the rights of others. He, too, can only see in the punishment and unpleasantnesses which his quarrel- some temper has brought on him the proofs of a malignant persecution. But in spite of these points of resemblance, our patient does not show the essential characteristic of such an affection — that is to say, a delusion. He certainly thinks that he is persecuted by his neighbours, but we may assume that he is not, in fact, treated in a very friendly way by neighbours who regard him as quarrelsome and malicious. What we miss altogether— - and this is a very important point — is the infernal connection of the innumerable lawsuits with each other, and their deriva- tion from an original and perfectly definite cause, which are essential to a querulous delusion. Again, while the querulous patient is often quite sociable and peaceable, apart from his delusion, we see our patient in the present case living at strife and discord with all the world. The circle of his enemies is always widened by new and definite causes of disagreement, and the direction of his attacks is often changed, while the higher courts and authorities are not involved in the blame. Lastly, for all his irritability, our patient does not carry on the battle with that joyful satisfaction with which the querulous count on a final victory over all the machinations of their enemies, but feels the perpetual disturbances as an annoyance from which he cannot escape in any way. Hence there is no actual develop- ment of the malady, although, of course, the points of friction between the patient and those around him are gradually in- creased by very obvious causes. For these reasons we cannot regard our patient as really suffering from a querulous delusion. He rather belongs to a not very large group of cases which we will include under the Morbid Personalities 309 name of pseudo-querulous, in which we have to deal with morbid personalities always on the alert to find a grievance, but with- out delusions. The gradual increase in the manifestations of disease seems to depend chiefly on the patient's taking up new unfriendly relations, but also on his impoverishment and, in the present case, on the changes brought about by age. It is very remarkable that the patient's wife, who tried to restrain him at first, developed a querulous delusion after many years, as the result of a lawsuit of her own. People of this kind are often able to draw others into their delusionary train of thought, and in the present case it was all the easier for her to do so because her husband must have been very highly susceptible to such an influence. LECTURE XXX MORBID CRIMINALS AND VAGABONDS Gentlemen, — The morbid inadequacy of disposition which we have learned to recognise as an expression of degeneracy is not only such a burden to its possessors that it keeps them per- petually behind their more fortunate companions in the com- petition of life, but in many cases it is also a serious danger to human society. We have already seen, in the last few lectures, how the most various forms of morbid idiosyncrasy bring their victims into conflict with law and order, from the moment when they make it impossible for them to conform to the conditions of a regular life. We also saw that, besides the morbid incapacity to conform to the fundamental conditions of human social existence, tendencies are sometimes piesent which are actually hostile to society. In this way are formed those various types of the habitual criminal who cannot find a place in the ordinary relations of life on account of their peculiar disposition. On the other hand, there are professional criminals with perfectly definite criminal intentions, and it is always quite as difficult to distinguish morbid personalities from those to which we are simply accustomed to apply the standard of moral repioba- tion as it ever is to judge of intellectual ability. Looking at the pale and slightly built married woman, aged fifty-four, who takes her place with a polite greeting, and answers our questions in a clear and connected way, you would hardly suspect that she has already been charged six times with arson, has spent no less than twenty- four years and three months in prisons and penitentiaries, and has only been at liberty for fifteen months in the last twenty years. The police reports and her own account of her past afford us a strange and gloomy picture of her life. Her mother died comparatively young, and one of her mother's sisters was insane. Her father was a dram 310 Morbid Criminals and Vagabonds 311 drinker and a thief. All her brothers and sisters, with the exception of a brother who has been in prison for theft and adultery, and is described as a " boozer," have left the district and disappeared. She was badly brought up, and was taught to steal when she was very young. She was imprisoned for theft for the first time at the age of nineteen. Further convic- tions of theft, fraud, and prostitution followed in the next few years. At the age of twenty-three she contracted syphilis. She committed arson for the first time at the age of twenty-four, setting fire to a shed in the garden of her stepmother's house. Her father was then in a convict prison, and her stepmother was living with a man whose wife was also a convict. There had been a quarrel, and she was forbidden the house, so she resolved to burn it down, that her stepmother might not be able to live there either. She very soon made a complete con- fession— as, indeed, she has generally done — and was con- demned to four and a half years' penal servitude. Four months after her release she committed arson for the second time ; this she confessed of her own accord two years later, to clear an innocent person of suspicion. She was search- ing for her husband, who had left her after a short time of happy married life on discovering her past history. She could not find him in his native place, and, according to her own account, she was so much annoyed, that she determined to burn down the house of one of his relations. A stable, which did not belong to any relation of her husband, was burnt to the ground. Three months after the expiration of a term of three years' penal servitude, to which she was then condemned, she informed the police at Strasburg that early in the morning a man called Stein had set fire to two market-stalls. When an inquiry was held, she voluntarily confessed that she had done this herself, and that Stein was an imaginary person. She had taken paper from a dust-bin and piled it up against the stalls so that they would burn. " I did that quite deliberately, and in my right mind," she says, " just for fun." When she had watched the lire blaze up for a little while, she went away, but soon came back. Then there came over her " an ' insecurity,' a feeling as if she were discovered, and ' everything ' were looking at her," so before any questions were asked she said that she had been there when the fire was started, and knew who had done it. She also asked if there were no news from her lodgings. Investiga- 3 1 2 Lectures on Clinical Psychiatry tion showed that she had taken lodgings under a false name, and had left her room two days before, aftei paying what she owed, leaving her belongings behind her. After seeing her stand for a long time at the corner of the street, looking back at the win- dow, her landlady discovered that she had set fire to the bed with a composite candle. " Why I set fire to it I do not know myself," she said ; " the people had given me no reason to do them harm." She was condemned to eight years' penal servitude, as the question if there were sufficient mental disturbance to make her irresponsible could not be answered in the affirmative. Her next commission of arson came four years later, in the penitentiary. Fire broke out at three o'clock in the morning in a stoie-room where the patient had been employed. It was noticed that she was very restless, and sat, fully clothed, on her bed. When closely questioned, she said : " I saw the red-hot coals in the fireplace, and the idea of setting fire to something sprang up in me. I could not resist it, and, when I was carrying in the water, I took three live coals into the room on a piece of broken earthenware. I threw them into the furthest of the tubs, one that was full of rags, and put three or four empty tubs on the top of it. I cannot give any reason for what I did. I could not restrain myself just at the moment when I had the opportunity ; it seemed as if an invisible force drove me to do it. God help me !" She afterwards withdrew this admission, and even now she pretends to know nothing about the affair. She made a feeble attempt at suicide by wounding her wiist with a pair of scissors, but was once more convicted, and was condemned to five years' penal servitude. After this she spent rather more than a year out of prison, as a servant in a public-house, until she quarrelled with the land- lady and ran away. Then her box was searched, and some things were found in it that seemed to have been stolen. Having come back and learned that she was threatened with a prose- cution, she set fire to the house on the following night and fled, but confessed her guilt as soon as she was caught. She says that at first she had thought of putting an end to her life, and felt very restless ; then her brother advised her " to do it." She has caused many more fires than she has evei been charged with — twenty at least — the first when she was a child of five or six. It has always been a great pleasure to her to play with fire. " Even now the idea is always occurring to me, ' H only Morbid Criminals and Vagabonds 3 1 3 this or that would burn.' It is like a fixed idea. Especially when I have matches in my pocket, then I think a kind of invisible force drives me to it." The thought comes over her quite suddenly, like a flash of lightning : "If I were to con- sider, I should not do anything of the kind." She says that sometimes she has first had something to drink ; at other times she has acted in anger. In spite of her defective training at school, the knowledge which our patient has subsequently acquired in the penitentiary rises above the average of that of women in her position, and she can tell her story very clearly. Her mood is on the whole indifferent, though friendly, but frequent changes have been noticed in it. She has sometimes been irritable and violent, conduct which often led to her being punished in the peniten- tiary ; at other times she has been merry and in high spirits or tearful and despairing in a rather theatrical way. She has often threatened to commit suicide, and has once tried to hang herself since she has been here. She had made the attempt several times in prison. She has sometimes spoken of dream- like hallucinations — that two devils pinched her in the night ; that men stood at the window and called to her ; that she had murdered seven children, and set fire to a couple of houses. She is not anxious about her future. She does not think that she is insane, and does not feel any actual remorse for what she has done. " I am not clear about it yet," she says. ** I always think I have not done it. I cannot bear to harm any living creature." The patient's physical examination shows that she is rather poorly nourished, but its most important result is the discovery of inaction to light in both pupils and exaggeration of the knee- jerks. There are also some whitish scars on the breast, and a thickening of the periosteum of the right tibia. In spite of her exaggerated and constantly-changing complaints of all kinds of pains and discomfort in different parts of her body, we cannot be certain that there is any disturbance of sensation. The most striking feature of this woman's life is the perpetual reappearance of the inclination to arson, which has determined her fate in the most decisive way. The absence of all compre- hensible motives on some occasions, their insufficiency on others, and the incurable tendency to relapse, must at once arouse the suspicion of disease. This impression is strengthened 314 Lectures on Clinical Psychiatry by the patient's account of the impulsive nature of her action, which we have no reason to disbelieve. We are, in fact, acquainted with a small group of morbid personalities, characterized by an impulsive inclination to perform certain actions, which are dangerous to the community, without any comprehensible motive. The tendency to arson seems particularly apt to appear in this way, but those gruesome women-poisoners, who in cold blood destroy a whole series of people against whom they have no grudge, or whom they may even love, may be included in this group. So-called kleptomaniacs are more doubtful cases, since the motive of self-advantage cannot generally be excluded. Criminal tendencies are not infrequently connected with sexual aberrations ; certain forms of kleptomania, for instance, with fetishism. Here we are on the border-line between professional criminals and the distinctly morbid group of criminals by im- pulse, in which we may very well include criminals from sexual aberration. The common and distinctive characteristic is the absence of any reasonable motive, and the powerlessness of all consideration to check the impulse, pressing on to its imme- diate fulfilment. Emotional excitement and alcohol seem, here as elsewhere, to lessen the power of resistance to the morbid impulse. Every alienist, as well as every magistrate, will be able to set many similar cases side by side with this, and we need not there- fore go further into other interpretations. Certain isolated hysterical features — the fluctuations of mood, the feeble threats of suicide, and the dream-like hallucinations — may be regarded here merely as general indications of degeneration. It is true that we not infrequently meet with morbid acts of arson in hysteria, but they are invariably committed in a state of semi- consciousness, while our present patient, although in a certain state of emotional excitement, was perfectly conscious of what she was doing, as is shown by her detailed descriptions. The absence of reaction to light in the pupils might suggest the possibility of general paralysis, but, quite apart from the fact that the rest of the physical examination does not give the least support to this hypothesis, it could not, of course, explain acts of arson going back into childhood. It is obvious that the affection of the pupils should simply be regarded as an after- effect of the previous syphilis. The condition we have before us here is essentially the ex- Morbid Criminals and Vagabonds 3 1 5 pression of a morbid disposition, and is therefore incurable. As it constitutes a very serious menace to the public safety, the patient's permanent detention in an asylum is unavoidably necessary.* It is much against his will, and only after urgent persuasion, that the pale and darkly-brooding, thick-set man, who will be our next object of study, has been induced to give an account of his changeful life. Hence, at first he only gives us short and often bitter and scornful answers, but on friendly persuasion he gradually becomes more accessible, and finally seems to take an actual pleasure in the opportunity of expressing his feelings in his own way. He tells us quite clearly and connectedly, and, indeed, in a very fluent and practised style, that he is of illegitimate birth, was brought up by strangers, and was im- prisoned for theft for the first time at the age of thirteen. This led to his falling into bad company, which drove him again and again to fresh breaches of the law, and rendered him careless and dissolute. His foster-father was bedridden for many years, and his foster-mother, of whom he speaks with a certain amount of affection, having the whole burden of house-work and bread-winning on her shoulders, could not give proper attention to bringing him up. " I was left to myself, in this state of liberty, without any oversight, and that was the foun- dation of my subsequent misfortunes. My naughtiness developed into faults of character without being noticed. My mother was so good-natured, that she thought she could refuse me nothing." She left him the money he sometimes earned at his own free disposal, and, even at the price of great sacrifices, provided him, as far as she could, with everything that other children, in better circumstances, had. " I only mention this in order that, in judging of the course of my life, no one may be prejudiced to suppose that my parents had a bad influence on me." He learned his lessons well at school, but his report said : '' With more industry and attention and more regular attend- ance he might be one of the best pupils." He very soon gave himself up to the pursuit of pleasure, and obtained the means he wanted in dishonest ways, easily deceiving his foster-parents, who trusted him. " This was the beginning of the path which led me on my dovmward course." A whole series of offences * The patient has now been for two and a half years in an asylum unchanged. 3i6 Lectures on Clinical Psychiatry followed. "I know from experience that, in judging of them from the police reports, many people are inclined to form an imaginary picture of me, and suppose that my actions have been ruled by a natural leaning to and interest in crime. That is not the case, however, but my better faculties and qualities could not develop owing to my position. On the contrary, circumstances forced me to develop my evil qualities. The foundation of my evil qualities was the pursuit of pleasure." He says that immediately after he was first sent to prison, shut up, as he was, in a cell, and disgusted with the food, he passed through a state of apprehensive excitement, as to the course of which he remembers nothing until he came to him- self with a headache, and found that he was lying in bed, with the doctor, the governor, and the chief warder busy round him. With regard to his subsequent history, we learn that he was very often convicted of theft and of begging, and that he has been sent three times to a penal workhouse. He admits his crimes without reservation, but also without any emotion what- ever, and tries to explain them as the natural result of his position and education, but especially of imprisonment, which makes it impossible for individuals to work their way back to a better position after their release. " Idleness, pleasure, in- discretion, revenge, covetousness, etc., are usually mentioned in the reports as the qualities which form the individual causes of crimes and misdemeanours, but circumstances have in most cases favoured the development of the bad qualities, and then it is only a question of time for their victim to come into conflict with the criminal law." For his own part, he has never acted from " motives a yard long," but simply followed the impulse of the moment. Prison discipline, which is always praised as humane, is quite impractical. Juvenile prisoners are not given the least opportunity of preparing themselves for a future occupa- tion. On the contrary, in most cases, their education is inter- rupted by their imprisonment, and the victim is injured for his whole life by his youthful offence. When defective education brings a boy into prison, and prison robs him of the best years of his life, the only result that can follow is a striving after un- limited freedom, in which lies the germ of a second offence." The fraternity of discharged prisoners consists of those who seldom allow an opportunity of doing a criminal action to pass, of those who are always waiting or seeking for such an oppor- Morbid Criminals and Vagabonds 317 lunity, and of those who systematically choose some particular dishonest means of gain for their future calling — pick-pockets and flat-catchers, for instance — or those who work with skeleton- keys, etc., either with or without accomplices. " It is generally difficult for those who have been often imprisoned to break with the past." They are received with distrust everywhere, and so can find no inward satisfaction, and can hardly resist the appeals of former comrades, who are ready to share their last bite and their last sup with them. In telling his story, the patient lets fall all sorts of incidental remarks about the conditions of life in different prisons and especially in the penal workhouse, hinting that prisoners are ill-treated there, can get no justice, and suffer in health. The last time he was convicted, when he had broken a pane of glass in a state of intoxication, he says that he was unjustly com- mitted to the workhouse, so he made a fearful scene with the magistrate, and also complained several times to the Ministry of Justice. Then they sent him to the asjdum, to shut his mouth, and prevent the discovery of manifold abuses, although he is not insane at all. He is only physically unwell, and suffers much from headaches and stomach troubles. There is a severe and peculiar nervous affection in his family, which takes the form of pains in the most various parts of the body ; his father died of it. His illegitimate brother had the falling sickness. They might let him go now, so that he could work his way up into respectable circumstances ; then bright and cheerful thoughts would come back to him. Our investigations have shown that this man's education is very bad, and points to frequent unauthorized absences from school. His later life is an almost unbroken chain of penal servitude and imprisonment. At the age of twenty-five he had already spent nine years in prison, always on account of his frequent thefts, generally practised with the help of accom- plices. The value of the articles stolen when opportunity offered, or by housebreaking, was generally small, and the proceeds were quickly squandered. In the course of the last nine years he has served a long term of imprisonment for an unimportant theft, and nineteen short terms for begging, and finally he has been committed three times to a penal workhouse. In prison he has always been described as very dangerous, depraved, and unwilling to work. He was frequently punished for idleness 3i8 Lectures on Clinical Psychiatry and insubordination, and was once flogged for an attempt to escape. In one of the convict prisons he was regarded as not quite sane, on account of a state of excitement, and was treated for some time in the infirmary. His frequent complaints of the treatment he received are very remarkable. As long as sixteen years ago he wrote a letter in which he obstinately maintained that he had been unjustly condemned, while other things that he really had done had not been mentioned. After this he often tried to get the proceedings connected with this or that conviction reopened. He complains of all these cases of real or imaginary injustice, and is generally able to set forth his rights very cleverly and effectively, appealing to the laws and constitution of the country, the general principles of justice, and the precepts of morality. He is very obstinate, = and declares that he will not let himself be oppressed, but will lodge complaints and defend himself in every possible way. " If, therefore, I am chicaned by anyone whatever, when I have done anything, then you can punish me, even judicially, but to be extra specially badly treated because I complain — that is, because I try to get my rights and will not let myself be oppressed — that I will not put up with again ; that does no good." A number of such petitions, very decided in tone and full of sarcastic expressions, were directed against his last com- mittal to the workhouse, and his treatment there by the officials and the doctor. These petitions led to his being bi ought to our hospital, as he was thought to be suffering from paranoia. When he came here he showed great reserve at first, and made all sorts of complaints of a hypochondriacal nature about his health, although his physical condition only showed a certain amount of anaemia. He soon began to occupy himself indus- triously, copied poetry, made notes from a text-book of alienism that a fellow-patient lent him, and gave us a detailed description of his life, from which we have taken the following extracts : " In my youth, up to the age of twenty-four, I allowed myself to be completely ruled by sensual impulses, so that they formed the source of my transgressions, without my being on that account particularly inaccessible to moral principles. My actions were the outcome of my mood for the moment. If I bad acted on moral principles, the evil impulses in me would certainly have been repressed, but my circumstances, at that time often difficult, would have demanded long-continued Morbid Criminals and Vagabonds 319 patience, without any improvement in my position. Therefore I felt no call to better conduct. My temperament was, and still is, easily excitable, and it was hard for me to suppress and control what was objectionable in me. Features of a vehemently passionate nature are often to be found in my life, and a tenacious clinging to inclinations, views, and sentiments, so that they grew into habits, and many peculiarities arise." " I must admit that trifling causes often unnecessarily anger and excite me for a considerable time, to such an extent that I am upset by them for whole days." He was always perfectly orderly, quiet, and polite in outward bearing, but cold and inaccessible, even to other patients. He made very circumstantial complaints about the behaviour of the warders, and regarded them with hostility and m.istrust. The account he has given of himself shows us clearly that the cause of his failure in life has not been defective mental endow- ment. He lays the blame himself on his pursuit of pleasure, and the want of self-control which has prevented his acting on " principles a yard long." Yet he is by no means one of those helpless creatures of the moment who let themselves simply be guided and actuated by chance. This is very evident in the obstinacy and determination with which he repulses every attempt to influence him. Hence we see that he is not at all suggestible, but inaccessible and resistive ; indeed, he has set himself in decided opposition to the prevailing order of society, which he practically declaies to be in part responsible for his poor success in life. He feels with some satisfaction that he is a martjT who is unjustly slandered and ill-used. If we find signs of exaggerated self-satisfaction in this account, in which no trace of real repentance can be seen, we are also surprised by the very strange contrast between the patient's clear and penetrating comprehension of his whole position and his absolute inability to put his knowledge into practice, not because his will is weak and vacillating in itself, but because moral incentives to action apparently have no influence over him. The wish to work his way up out of the misery he so clearly recognises has never acquired the passionate force with which true repentance acts on the will, and the longing for freedom, an independent position, and the respect of his fellow- men is not enough to spur him to repress his momentary appe- tites, or to exert his strength continuously. Even now, when -^20 Lectures on Clinical Psychiatry his past career has really made his return to a regular life almost impossible, he does not feel this fact so keenly as the little annoyances of the day, and he does not take the least trouble to prepare the means of rising to a more respectable life. As, in spite of this, he shows active intellectual interests and occupies himself industriously of his own accord, we can scarcely avoid the conclusion that this is a case of moral atrophy, with good mental endowment. It is still possible to ask the question whether this is a morbid phenomenon or not. We knew from manifold experience among the sane that mental and moral capabilities are quite independent of each other, and that deficiency in either only becomes morbid when it reaches a certain arbitrarily fixed degree. Yet we may regard a marked disproportion in this respect as a sign of de- generation, as is proved by its intimate causal connection with other forms of that condition. In the case described the mor- bidity oi the patient's nature, as a whole, is made additionally probable by the repeated states of excitement (though these are certainly not quite clear clinically), the hypochondriacal ten- dencies, and the " querulous " features. The most severe forms of purely moral atrophy have been given the name of " moral insanity," though this designation is also applied to other conditions of very different kinds, and particularly to simple want of self-control and constitutional excitement. If moral insanity is understood in the sense we have indicated, it is characteristic of the " born ciiminal," who chooses and follows his particular course of life because moral considerations have no power over him. The levers which education might work are wanting, and the patient is therefore fundamentally incapable of improvement. The greater part of these degenerates are to be found in our prisons ; a small remainder, with more obviously morbid features, end their career in an asylum.* Another of Nature's stepchildren is the goodnatured-looking, prematurely aged man of forty-four, who was sent here lately for chronic alcoholism. When he is spoken to, he is rather embarrassed at first, but soon begins to describe his life with unexpected animation of speech and gesture, while he often has difficulty in keeping back his tears. His father, who had a • The patient escaped soon after, and a few weeks later he was con- demned to eighteen months' penal servitude for theft. He is considered ' paranoidal.' Morbid Criminals and Vagabonds ^21 weak and hesitating character, died comparatively early ; his mother was extremely passionate, and prone to anger. She afterwards married a second time. The patient describes him- self as " cowardly by nature, just like a hare, without the spirit of enterprise." As a child he says that he was reserved and solitary, and never fought with anyone ; at the most he only scolded like a little turnspit barking. " When it comes to the pinch, I am no good." Hence he did not like the trade of a butcher, which he was put to learn, and ran away. He did not persevere long as a baker either, but took, while still a lad, to a vagrant's life, in which he has continued, with short intermissions, ever since. At first he went about with other men, who, because he was a pretty boy, misused him sexually, and paid for him, but later on he kept more to himself. Although he had absolutely no sense of locality, and was always losing his way, he felt an irresistible craving to see the world, and never stayed anywhere for long together, even when, as happened more than once, he had the prospect of permanent employment of a kind he liked. The cause of this behaviour was a " fearful inconsiderateness," inherited from his mother. " The nervous restlessness, the hunt after change and variety, spoiled everything. I was like a little child till I was past twenty ; what little sense I have has only come in the last ten years." He never stayed more than three months in one place, but wandered, year in and year out, from his native Saxony through Germany, Austria, Hun- gary, Italy, and France, and once or twice joined bands of gipsies. He earned his living, after a fashion, by making children's toys of wood and pasteboard, and did not feel equal to serious work. " More helpless than a child of twelve in any business, too awkward for any manual trade, and with an in- surmountable disinclination for any work which is in the least degree monotonous, I can have none of the pleasure and interest which are necessary in every kind of occupation." He has tried everything, but has always found himself useless, and sees that the success of the work was " better guaranteed " without him. When he was in need there was nothing left as a last resort, except to beg, but that was very difficult for him. " Even now I cannot manage it ; I cannot go up to anyone. It is contrary to my nature, and I have a feeling of revolt when I have to appeal 21 322 Lectures on Clinical Psychiatry to the compassion of another — a sort of shame and pride." He learned from his comrades' example to drowoi this feeling in spirits. " I think nothing of it when I am drunk. When I had no money, I would sooner starve than beg, unless I had had something to drink." His " notorious cowardice " also hampered him in hawking his wares and in looking for work, as he grew dis- heartened at once if he was rudely treated, or his application had not an immediate result. He therefore drank to get courage with so much zeal that, finally, there was not a day when he did not get drunk on wine, spirits, cider, or beer. He had delirium several times, generally when he was locked up, as he was twenty or thirty times, for begging and vagabondage. He says that he has never been in prison for anything else. When he had work, he drank very little, and took no spirits at all, for he did not really like them ; but when he was on the tramp or in inns, where there was much drinking, he broke out again at once. Sexually, he seems to have confined himself to the onanism he had practised from his youth. He only sought for intercourse with women once or twice, and generally felt too shy. He would like to marry a pretty girl, and can amuse him- self quite well with one, " but dare not make any proposal." He has a horror now of intercourse with men, at any rate, when, he is sober. About fifteen years ago, while he was in prison, a comrade taught him the art of modelling flowers and figures in bread, and he has brought it to an astonishing degree of perfection. When he shows us his little works of art — baskets of flowers, clumps of trees with their branches, " hunting scenes," and " battle pieces " — his eyes sparkle, and he grows quite en- thusiastic. " In making my things," he says, " I feel that I am as good as anyone else, and self-respect takes the place of my former servility." On this dexterity depend his hopes of a. brighter future. He will give up drinking altogether. " Per- haps the pleasure of success will drive away the demons that used to torment me more quickly than I can imagine. I feel certain now that only my art can be the means of my attaining to the end so passionately desired. I ask for nothing more than to be a man among other men. I care absolutely nothing for material enjoyments. On the contrary, I despise luxury and even comfort. What I wish for is the honourable regard of my fellow-men. I should like to know that this feeling of Morbid Criminals and Vagabonds 323 inferiority to any ordinary man was dead once for all — this feeling of having to grovel abjectly before any clodhopper, this inexplicable fancy that others have a secret power over me, this medley of slavish humility, fear, shame, apprehension, faint - heartedness, and misanthropy." He thinks that the theatre will give him particular pleasure. "There was a time when I could recite the first part of ' Faust ' by heart from end to end. It is on Goethe's ' Faust ' that I have formed my view of life, but I am too uneducated to understand it all. But, after all, that is a matter of absolute indifference, for no mortal man can know the real truth. I have decided on Italy to winter in for the future ; if only religious affairs go better, I shall have a great field for my art there." The patient's physical condition presents no disturbances wort'i your attention, except for fine tremors of the tongue and of the outspread fingers and marked swaying when the eyes are closed. His behaviour throughout the time we have had him under observation has been perfectly qaiet, polite, and sensible. He has worked with great industry at the manufacture of a number of his delicate bread models, and drawn up a full and very well written account of his life. You will form a very imperfect idea of our patient's condition if you set him down merely as a drunkard. No doubt drunken- ness, as in the case of 70 per cent, of vagabonds, is partly re- sponsible foi the state of wretched demoralization into which he has gradually sunk ; but it is clear from his own description that entirely different reasons first led him to embrace a vagabond career, and that even his tendency to drink has a very special origin. It was his incapacity for " mechanical work," his unsteadiness and aversion to all restraint, which prevented his settling down. By this characteristic he belongs to the group of vagabonds called in Germany Orientkunden (Levanters), because their restless love of wandering drives them far from home, especially towards the South. The patient's skill and perseverance in his extraordinary " art," and the intellectual activity which, even in the most wretched circumstances, has inspired him with an enthusiasm for poetry and philosophical questions, present a very strange contrast to his inability to earn his daily bread. He evidently has a marked one-sidedness of nature, which has been fatal to his position in life. The great obstacle to his success, however, has been the want 21 — 2 324 Lectures on Clinical Psychiatry of self-confidence which he keeps on describing and lamenting in ever new phrases. He was unable to make himself a position anywhere, to overcome difficulties in a practical way, or to repel attacks, and even the trifling difficulties of daily life so much dis- heartened him that he was afraid to undertake any responsible occupation. To this may be referred his antipathy to " all compulsion." He felt the discouraging effect of this frame of mind, which is a common expression of psychopathic degenera- tion, very keenly. Hence he took to alcohol, which dulled his over-sensitiveness to the rough contact of the outer world and drove away his shyness, until he became equal to the demands of his vagabond life, his daily task of begging and hawking. It is only his gradually developed artistic faculty — his " thing," as he calls it — which has aroused his self-respect, and he hopes to find in it the support which will prevent his sinking back into the miserable life of the road.* This example of the strange tribe of vagabonds may serve to show you how little the reality sometimes corresponds to popular belief. The great mass of vagabonds, however, consists essen- tially of the feeble-minded, who for some reason or another are not under the control of their families. Their incapacity pre- vents their finding permanent work, and, under the influence of bad example and the demoralizing effect of drink, they fall into the monotonous round of the high-road, the prison, and the workhouse. Next we find a group of epileptics, who are always losing their places on accovmt of their infirmity, or leave them suddenly during their periods of depression. Then we meet with a certain number of drunkards, who have seen better days, but who through alcohol have lost all taste and capacity for work. There is also a not altogether inconsiderable number of hebephrenic dements, who have become childish and unfit for work, either imperceptibly or as the result of an acute mental disturbance. These dements, in a later stage, develop occasional and tran- sitory states of excitement, hallucinations, and delusions. Again, there are isolated cases of luetic and even of paralytic feeble-mindedness. The remainder are psychopaths of different kinds, such as the case we have before us now — men for whom the development and employment of their better qualities is made permanently impossible by inadequacies and morbid admixtures. You will easily see that it is mere loss of labour * We will try to help him as far as possible in this endeavour. Morbid Criminals and Vagabonds 325 to try to guide this heterogeneous crowd into the straight road by means of the panacea of short terras of imprisonment, or that much-dreaded punishment, committal to the penal work- house. So far as it is possible to diminish the terrible plague of vagabondage at all, it can only be done by treating each of these groups in accordance with its own special character. The first step in this direction is their scientific investigation. LECTURE XXXT IMBECILITY — IDIOCY Gentlemen, — You will often have noticed in the course of these lectures how little the idea formed by the laity of the be- haviour of the insane corresponds to the reality. Many of the patients you have examined here hardly presented anything remarkable at first sight. They gave intelligent answers, and behaved with propriety ; not a few had a distinct feeling of illness, and some even had a clear understanding of the special nature of their malady. Yet on closer inspection we have usually been able to find disturbances which at once showed the stamp of their morbid nature and undoubtedly passed the bounds of sane behaviour. It is otherwise in those forms of insanit}' where we only find deviations in degree from the more or less arbitrarily drawn lines marking the limits of mental health. It is true that, at the farther end of the ladder leading imperceptibly from the frankly morbid to the commonplace, the distinction is easy. But there must necessarily be many intermediate steps, approach- ing the morbid at one end and the sane at the other. When we talk to the woman, aged thirty-six, who now takes her seat before you with a good-tempered, rather shy greeting, we very soon see that she is mentally badly equipped. She knows where she is, and recognises the doctors and the people about her, and can describe them fairly well, but as soon as she is asked what year it is, she makes quite helpless guesses, although she can tell the month and the day of the month — at least, approximately. She is also uncertain of her age by several years. But she tells us the story of her life with intelligence, though diffusely and incompletely. Her parents are dead. Her father was fond of drink, but was seldom drunk. He lived on bad terms with her mother. Three brothers are dead, and three others are alive and 326 Imbecility — Idiocy 327 well. The patient did badly at school, owing to the weakness of her eyes, as she says. After her parents' death, of which she can only give the date very vaguely, she lived with a foster-father, and tried once to go into service, only keeping her situation for two months. Afteiwards she was sent to an idiot asylum. The reason for this was the circumstance that she bore a child almost every year. She has had eight children since she was twenty years old, of whom six are still alive. She can only give a very imperfect account of their ages and names, and of where they are. Once she escaped from the asylum, but went back of her own accord after a short time. She had her last child by a warder of the asylum, and therefore it was decided to send her elsewhere. She agreed to this, for she knew that she had done wrong. So she promised the Poor- Law authorities that it would never happen again, who said that they would overlook it once more. She excuses herself by saying that the warder promised to marry her, and that it was all to have been kept very quiet. She thought she would get out of the asylum by marrying, but when things had gone so far, " he " went away. She quite understands that she must be shut up if she has a child every year. She is not frightened by the prospect of staying a year in the hospital, but only says that then they will see what fine stockings she can knit. She feels perfectly well, and says, " I am not ill ; I can work." She can earn her living by selling fruit or taking a situation. Her general knowledge is extremely small. She can do simple sums, but gives them up whenever any special mental effort is required. She does not know the name of the Grand Duke or of the Emperor, nor what river Heidelberg is on, and can name absolutely no towns, rivers, or countries. A few scraps of religious instruction remain, learned by heart, without being understood or mentally turned to account. Yet the patient is skilful in all kinds of housework, works willingly and industriously , gets on in the little circle of the ward without any difficulty, helps in a practical way where she can, and causes no disturbance. She notices improper behaviour in the other patients, and inter- poses to protect the doctors from abuse. Her mood is almost always cheerful, contented, and free from care ; it is only now and then that she is anxious to get out, seems to miss her children, and says that she can take care of herself, and that they have no right to keep her. In the patient's physique, you observe at 328 Lectures on Clinical Psychiatry once the low forehead and very small skull. Her expression is imbecile and vacant, and her palate is very highly arched. Except for these, there are no abnormalities worth mentioning. You cannot be in any doubt that this is a simple mental state of weakness. The patient's mental and emotional behaviour produces the impression of that of a child eight or ten years old at most. Her knowledge, indeed, is on a much lower level, but given ordinary circumstances she can find her way about much better than one would expect from the evident scantiness of her stock of ideas and the weakness of her judgment Her attitude towards her sexual failings is exactly that of a child to its naughti- ness. She is glad when she is forgiven, and has absolutely no sense of the moral significance of her conduct. She is very far indeed from worrying or thinking about the results of her actions, or about her future at all. Easily guided and obliging as a child, she adapts herself to whatever happens. Thus, her condition may, on the whole, be best understood as the failure of the mental personality to rise above a low level of development, or as a high degree of that inadequacy, unfortunately not unusual in even normal life, which we call stupidity and limited intelligence. In this case, unlike the forms of feeble-mindedness considered hitherto, there are no remains of previous mental disturbances — delusions, hallucinations, depression, or eccentricities of behaviour and action. It is only in degree, and not in their nature, that the mental, emotional, and volitional acts of our patient are different from those of simple people, whom we still regard as within the pale of sanity. In particular, we miss the very great dis- crepancy between knowledge and capacity which we have always seen in acquired feeble-mindedness. There we always saw the patients make shipwreck in life, although they often still possessed considerable knowledge. But, in the present case, the patient is fairly equal to the ordinary demands of daily life, while her mental development does not go beyond the most immediate experiences of the senses, and fails altogether as soon as more general ideas and attainments are in question. The patient's ability is incomparably greater than her knowledge, and, if the increasing number of her illegitimate children had not led to her being sent to the asylum, she would have found herself a place in the outside world without great difficulty. This capacity for the practical conduct of life, in conjunction with a very low grade of higher mental activity, is characteristic of the congenital feeble-minded- Imbecility — Idiocy 329 ness which is called imbecility in contradistinction to acquired dementia, with its absurd behaviour. But even imbeciles are naturally unable to satisfy the more difficult demands of life. Sexual relations in the present case, and in others alcohol, bad example, or a propensity to idleness, are the reefs on which they are wrecked in consequence of their inadequate equipment for the battle of life.* As imbecility depends on a congenital or early acquired affec- tion of the cerebral cortex, it cannot be influenced in any way by medical treatment. But an education carefully adapted to the patient's idiosyncrasies will always bring about a certain development of the existing faculties. In ordinary schools feeble-minded children not only make no advance themselves, but they also hinder their school-fellows. In many towns the course has now very properly been adopted of separating mentally deficient children, and teaching them in auxiliary classes, where the course and method of instruction are suited to their capacity. In the more severe forms of congenital feeble-mindedness these auxiliary classes are not enough. The education of children of this kind must be transferred to special asylums, with teachers specially trained to the work. Here you see a man, aged twenty- four, who has lived in an idiot asylum since he was seven years old. He showed a marked degree of mental incapacity even as a little child. Unfortunately, we know absolutely nothing of the first part of his life. The patient answers our questions willingly, but in curiously broken and ill-formed sentences. He knows that the place he comes from " is an asylum -house and asylum children." Here he makes the remark, " If one has learned already and attends better, one can learn an awful lot." He has learned reading, writing, arithmetic, and a great many other things. He calls his present place of residence an " infirmary," and knows the names of all the people about him quite correctly, although he has no real idea of the particular meaning of the asylum. He can only name the present month and his birthday, but not the date of the year, even approximately. He gives his age correctly, but cannot reckon time. He recognises pictures which are placed before him, and names them correctly, adding remarks which show that he understands what he sees, such as " Duck-bird, swims on the water," " Cat likes to drink milk." He can also read, with the measured * The patient has been for many years in a nursing asylum unchanged. 33° Lectures on Clinical Psychiatry scansion in which school-children learn their lessons, breaking up the words into syllables. He can repeat a number of texts and verses of hymns he has learned by heart in the same way. When told to do so, he sits down at once with his hands folded, bows his head a little, and begins in his school fashion to repeat the Gospel for Christmas. And we find that he understands the sense of it tolerably well. Besides the religious ideas of heaven and hell, the Child Christ and angels, which he brings forward again and again, his mind is filled by recollections of his life in the asylum — the " ribbon-work, blue, white, and red together," " doing weaving," " doing baking," " cleaning stair, cleaning up garden, making good dough, praying to God," and also by a visit from his former head -warder, whom he recognised at once and greeted in a friendly way. He does sums with small figures, slowly and with the help of his fingers, but correctly. He knows money up to a mark. " If anjone wants to know, can reckon well — for instance, if anyone asks how much is three hundred pfennigs, then I think now I must attend ; then one says three marks. When anyone asks eight hundred pfennigs, then one says eight marks ; a thousand pfennigs, then one says ten marks." He calls a ten-mark piece a gold pfennig, but cannot tell the value of it. He cannot name the country in which we live. " I have not had so' much time." Neither does he know the name of the Grand Duke. " They do not say so out there." " Emperor I know, Frederick William." The Grand Duke lives at Karls- ruhe ; bis birthday is on the 9th of September, " and I will tell you that, too, directly, the Emperor lives at Berlin." The patient knows the points of the compass, and gives them correctly even in the room. His mood is satisfied on the whole ; he is childishly sociable, and evidently proud that people are taking notice of him. He very willingly plays a simple tune on a mouth- organ, pipes on a little bottle, imitates a cuckoo through his hollowed hands, and is childishly pleased with the applause he wins. His gestures are lively and expressive, and the play of his features, which often amounts to grimacing, reflects his feelings very plainly. As we have already said, the patient's speech is very remark- able. He is quite unable to construct a sentence, but puts the separate words loosely together, according to their general con- struction, so that one can fairly well guess what he means. The Imbecility — Idiocy 331 more or less comprehensible sense, which plainly appears in this confused series of words, quite distinguishes it from the confused speech of katatonic patients, to which it has a superficial resem- blance. Our patient's talk reminds us rather of the broken speech of uneducated people who have learned a foreign language very imperfectly and by ear alone. Thus he explains, when asked how old he is : " If you once know how old I am, listen • how much old, am twenty-three old now — that is, 23 August month, add one month ; when one is over, one year older, 17 day is name day, then joy ; do you know, that is just Sunday. I have always learned well, attended beautifully well, is like the Emperor's birthday." He speaks with rather a stutter, but sometimes very quickly, and talks a great deal. He often inserts meaningless words and phrases that he has often heard when he is being taught, especially " attended " and " good-morning." " The good God can do a great deal on the earth — good time — attended well — learned in the school, have learned arithmetic too ; I can read Latin too. Good-morning ! In winter I split wood-saw ; that was good work." As you see, the patient's talk is very divertible, and he intro- duces all kinds of irrelevant ideas into it. His stock of ideas is evidently very scanty, and he always repeats the same thoughts and expressions. He writes with a steady hand very slowly. His writing is large, regular, and very legible and careful. Its purport shows the same peculiarities as his speech — almost com- plete absence of construction, digressions of the course of thought, monotony, and poverty of ideas. Yet the patient has, of his own accord, made a quantity of drawings, some of them coloured, representing in a childish way houses, Christmas-trees, angels, carriages, and quite a number of objects ol daily life. As they are generally 1 epeated in exactly the same form, and are very well executed, they must be reproductions of subjects he has practised. He explains them in the same quaint way as he did the pictures which were shown to him. We must regard the stage at which mental development has been arrested in the case before us as considerably lower than that of the previous patient, though the difference m the stock of ideas itself may not be very great. But here we see the result of a careful education lasting for many years, while the other patient only gained such additional mental endowment at school as she could pick up under ordinary conditions. Accordingly, 332 Lectures on Clinical Psychiatry she showed very little trace of what she had been taught, but she understood her position far better than our present patient. In his case, we can easily see that the stock of ideas has only been won by the direct agency of the senses, while all further working up of such material, particularh' the formation of general ideas and conceptions, is almost entirely absent. With this there is associated a ballast of learning acquired entirely by memory and belonging, characteristically enough, almost exclusively to the province of Bible scholarship. But what marks the patient's low mental position most clearly is the imperfect development of his speech, which, in spite of all instruction, has remained on the level of that of a child three or four years old. We will there- fore be justified in regarding this case as belonging to those very severe forms of congenital feeble-mindedness which are generally classed under the name of idiocy. Idiocy, too, depends on an earlj' and general affection of the cerebral cortex. In this connection, one generally thinks of the arrest of development as being due to some kind of malformation. It seems, however, that we have to deal, in by far the greatest number of cases, with an actual disease, involving the partial destruction of the constituent parts of the cortex. These dis- turbances often take place even before birth, and also often enough in the course of the first few years of life. No consider- able physical disablement usually appears, and our present patient's physical examination shows no abnormalities worth mentioning, e.xcept the height of the palatal arch. But a sign of the brain disease has remained in the form of epileptic attacks. These are often observed in such cases, and are considered an unfavourable sign for the further development of the condition. They have existed since the patient's childhood, and have been obser\^ed in this hospital about every four weeks, singly or in little groups. States of apprehensive excitement also appeared at frequent intervals, in which the patient was afraid he would be made away with, screamed loudly, tried to get out, and was violent and unruly. Sometimes these conditions, which were the cause of his being brought to the hospital, set in even at night, but generally they passed off again in a few hours. Our patient's malady is, from its nature, incurable. All that can be done by education has been done in his case. He is not fit for an independent place in life, yet it will still be possible to utilize the powers which have been given him, to a certain extent, Imbecility — Idiocy 333 in the work of an asylum. But the epilepsy accompanying his malady gives occasion to the fear that, in course of time, there may be a still further loss of mental ability.* As the name of idiocy includes all those disturbances which lead to imbecility in early childhood, and so nip in the bud psychi- cal development, we can hardly speak of it as a single disease. Indeed, idiocy may be due to very different varieties of disease, though we cannot at present distinguish them. Individual cases of idiocy do, in fact, show very great divergencies, not only in degree, but also in the kind of imbecility. A few weeks ago a boy, aged twelve, who belongs to a very degenerate family, was brought here. His mother spent many years in an asylum, his father is said to have been occasionally deranged, a near relation came to his end by suicide, and his grandfather was extremely " nervous." The boy is the sixth in a family of eight, of whom the last five are all said to be mentally ill-endowed and clumsy. He was born at the full time, but had very frequent convulsions from the time he was four weeks old, which kept on recurring for several months. His speech was late of develop- ment. His education presented great difficulties, as he was disobedient, unstable, and easily excited. At school the boy made very poor progress, and was considered idle and inattentive. The teachers said he could do very well when he liked. Latterly he could not be made to go to school at all, and threw himself on the ground if anyone tried to force him. For the last two years he has run away from home whenever he saw that he was not watched. Latterly he stayed out even at night, wandered about aimlessly, hid himself, climbed about in lofts and cellars, and dug himself holes, from which he finally emerged, looking dirty and neglected. All attempts at education proved ineffectual, and gentleness made as little impression on him as scolding or blows. If he was remonstrated with, he only answered, " I can't ; I won't." He showed no attachment to his family, or at the most only to a younger brother, but he liked playing with other children. He often laughed immoderately, and once did so for a whole night. His sleep was very much broken and his appetite capricious. He behaved badly at meals, generally crouching under the table. He was very irritable, and liable to get into a quite senseless rage. Then he destroyed what- ever came into his hands, and even threw things out of the window. * The patient has been in a nursing asylum for five years unchanged. 334 Lectures on Clinical Psychiatry He was unreliable and untruthful. As he finally threatened to set fire to the house, he was brought to our hospital. You see that the boy is small for his age and poorly nourished, and gives the impression of a child about eight years old. His ?kull is unusually small and asjTnmetrical. The lobes of his ears are soldered, and his eyes are small, but there are no other physical abnormalities worth noticing. He is clear about where he is, knows who brought him here, can tell the names of all the patients and warders with whom he has come into contact, and even knows in which beds they sleep. He does arithmetic, so far as he has learned it, very quickly and correctly, but addition, and still more subtraction, are much harder for him than multipli- cation. He knows scarcely anything of towns, rivers, and countries, and does not know the capital of Baden or of Germany. Neither has he heard of the Battle of Sedan. The Emperor is called Frederick. Bismarck is the Sovereign in Germany. He can enumerate only a very few dates, but a fair number of animals, though he cannot be induced to show any regard for the living creatures in air and in water. He cannot repeat the Ten Com- mandments, and has very confused and deficient religious ideas. " Sin is when one spoils bread or shoots birds dead." He knows that one ought not to do that, but cannot exactly say why. The boy's mood is cheerful. He likes being here, does not feel in the least homesick, and never asks after his relations. He behaved quite apathetically when they came to see him. He has soon grown familiar with his new circumstances, associates with grown-up people without any shyness, is always interrupting impertinently, is not afraid of excited patients, but laughs at them, and does not learn to know better when some of them scold, threaten, or even strike him. He cannot be induced to do any continuous work. Although he reads quite easily, if you give him a definite task, he does not go on with it, has very soon for- gotten what it was, and does all kinds of childish mischief. It he is forced to read, he can repeat whole sentences almost, or even absolutely, word for word, but hardly takes in a trace of the meaning. Next day all is completely forgotten. His behaviour is familiar. He greets the doctor from a distance, goes with him on his visits, gives information, joins in the conversation, and lets himself be made use of for trifling services. Under the discipline of the hospital, hardly any disturbance can be seen in the patient's outward bearing, and none at all in Imbecility — Idiocy 335 his memory and sense-perception. But his judgment and his power of working out his experiences are on a very low level, corresponding at the very most to those of a child five or six years old. Yet the most prominent feature of the clinical picture is complete want of emotion — indifference to his nearest relations, absence of home-sickness and of shyness before strange and even threatening people, and inaccessibility to educational influences. In contrast to the behaviour of the last patient, it is in this depart- ment that the morbid disturbance is by far the most strongly marked, although the severe impairment of the understanding is only hidden from a superficial examination by the surprising power of memory. The particular form of imbecility in the case before us will perhaps remind us of our experience in dementia prsecox, of which the final stage is also often marked by retention of memory, with great weakness of judgment and loss of emotional activity. It is true that the disturbances of behaviour and action, which are usually so clearly marked in that disease, are completely wanting in our patient, if we disregard his instinctive running away. But still, it is conceivable that some relationship may exist between this form of idiocy and dementia praecox. There is a considerable group of cases in which clearly katatonic dis- turbances develop on a soil of feeble-mindedness existing from childhood. In our present case the convulsions in childhood might mark the onset of the disease of the brain, of which we see the result before us now. With the boy's good though fugitive memory, a further development of his knowledge may result from careful instruction in an asylum for idiots. But whether it will be possible to develop his defective emotional life to any extent, unfortunately, seems very doubtful.* * The boy has now been for eight years in an idiot asylum. He is under-gardener there, and is childish and rather restless and heedless, but hard-working and conscientious. LECTURE XXXII CRETINISM-CONCLUDING REMARKS Gentlemen, — The appearance presented by the woman, aged thirty-two, who is to be the last subject of our cHnical investiga- tions is a very remarkable one. The stature of this grotesque being is extremely stunted, while the outline of her body is almost devoid of form. With a height of 137*5 centimetres, the weight is 70*5 kilogrammes, and the circumference over the navel 108 centimetres, and obliquely over the mammary glands 104 centimetres. In the middle of the upper arm it is 27-5 centi- metres, and in the middle of the thigh 54 centimetres. The head is very large in comparison with the height, and is 58 centi- metres in circumference. It is placed broadly on the thick-set body, almost without any constriction in the form of a neck. The arms and legs are rather short, and the hands, feet, fingers, and toes are as small and delicate as those of a child. On closer examination, it is seen that this remarkable dispro- portion between the head and the height, and especially between the trunk and the extremities, is really caused by an enormous thickening of the skin. The build of our patient's skeleton is rather slight, and the muscles are only moderately developed, but the skin hangs in thick pads round the thorax and abdomen and the upper arms and thighs. Behind the neck it forms a hard cushion, which can only be moved as a whole, looking from the side exactly like a considerable kyphosis. The breasts hang down in the form of large flabby sacks, and huge masses of skin quiver round the upper arms, on the surface of which it is no longer possible to take up a fold. The clumsily-thickened neck disap- pears to a great extent in a gigantic double chin, reaching from ear to ear. The face is broad, the eyes project slightly, the cheeks form firm, 33^ Cretinism — Concluding Remarks 337 rounded cushions. The root of the nose is sunken, broad, and flat, and the small organ itself is turned up. The malar bones pro- ject. The lobes of the ears are almost entirely wanting. The hair and teeth are fairly well developed, while the eyebrows are scanty. The aspect of the face is fixed and mask-like, as even in laughing and speaking all the finer plays of expression are absent in the heavy features. The thickened skin offers a firm and elastic resistance everywhere, and there is no pitting on pressure. The movements of the eyes, pupils, tongue, arms, and legs are normal, and there is nothing abnormal to be found in the reflexes. The patient's psychical condition makes it impos- sible to test the sensibility of the skin exactly. If you try to prick her with a needle, she pushes you away violently, but leaves the needle sticking in when her attention is diverted. Tapping the middle branch of the facial produces a slight twitching of the upper lip. The pulse is small and easily compressed. Our attempts to obtain information as to the patient's psychical condition meet with considerable difficulties. She looks round her curiously, but pays no attention to the questions addressed to her, or, at the best, now and then gives an evasive and generally a jocular reply. Her name is " Nobody," she is forty-five years old, was born on the 45th of August, is the daughter of the regiment, is a cattle-drover at home. If she is pressed, she becomes irritable, throws out some indecent terms of abuse, and gets up clumsily to run away with mincing steps. At the physical examination, too, she resists rather violently, at first cries " Go away," and " Leave off," and hits out, but all in a playful way. Finally, she acquiesces without any difficulty. To many of the questions she replies " I do not know," or makes use of quite senseless and abrupt expressions. It is therefore quite impossible at present to form an idea as to whether she is clear about her surroundings. I may, however, add, on the strength of occasional utterances of the patient in talking and writing, that she knows where she is, and also knows the names of the people about her quite well. Her mood is cheerful and exalted. She often breaks out into a short, jerky laugh, without any cause, or begins to sing a ballad or a street song in a shrill voice. She obeys orders with reluctance ; she puts away her hand when she is asked to give it, but then strikes hands with a loud clap. She sometimes repeats words she hears or questions that are asked her several times over, and she has 22 338 Lectures on Clinical Psychiatry a decided tendency to make rhymes, such as Herr Lehrer, Herr Scheerer ; doctor, gelockter. She writes her name correctly on the blackboard, and does a simple sum. All further attempts to test her knowledge are defeated by her resistance, accompanied by vacant laughter and clucking movements of the tongue. It is easily seen from the patient's behaviour that she suffers from a considerable degree of imbecility. This imbecility reminds us to a certain extent of the last stages of dementia praecox, more especially in the vacant laugh, the echolalia, and the indications of negativism. But the patient's physical con- dition is so remarkable that we must now turn our attention to it. The thickening of the skin can only be due to myxoedema, and points to the fact that the activity of the thyroid gland must have been defecfive. If we touch the patient's neck, which is 32"5 centimetres in circumference, we feel on the left side, near the windpipe, a swelling the size of a small apple, and as hard as stone, which is evidently the apparently calcified thyroid gland. The patient's dwarfish stature, and the enlargement of the skull^ show that the activity of the gland must have ceased in childhood. Therefore we have not to deal with ordinary myxoedema, but with that form of the disease which attacks even children, and is called cretinism. Cretinism is an endemic disease, which is rather widely spread, especially at the foot of the great mountain ranges. It affects a number of different species of animals. The germ of the disease seems to be carried by drinking-water. Under its influence, the thyroid gland shrinks or degenerates, and the change in the skele- ton, the skin, and the nervous system seem only to be caused by the failure of the action of the gland. Our patient does, in fact, come from a neighbourhood where cretinism is indigenous, and of a family in which insanity, including that of the cretinistic nature, has often occurred. Her father was feeble- minded, and so are her brother and a maternal uncle, while a cousin on her father's side suffers from maniacal-depressive insanity. The patient was mentally ill-developed from her childhood, and very obstinate and difficult to bring up. The menses only appeared when she was eighteen years old, and were often in abeyance for a long time, even for a year. After the period of physical maturity, the patient complained a great deal of headaches and loss of sleep, was excited and irritated, and was Cretinism — Concluding Remarks 339 finally brought to our hospital on that account nearly eight years ago. She proved even then to be very imbecile, and gave httle more information than she does now. Sometimes she expressed vague ideas of persecution and grandeur, and spoke of sexual assaults at night, and of a gold ornament. Generally she was a good deal excited, chattered to herself incoherently, and more or less unintelligibly, made rhymes, puns, and simple jokes, pulled up the doctor's coat, pulled his pocket-handkerchief out of his pocket, gave him a push when he was not looking, ran about with her clothes pulled up, masturbated, and tore up clothes and bedding. She looked at her shapeless features reflected in the window-panes with great satisfaction. At other times she was quieter, unsociable, and surly, but always extremely poor in thought and devoid of deep emotion. When visited by friends or relations she remained quite indifferent. She was occa- sionally dirty, even intentionally, but could be trained to order and cleanliness to a certain extent. Her sleep was good, and her appetite still better, and consequently she increased in weight pretty steadily from the time of her admission, gaining about 21 '5 kilogrammes. Under these circumstances, the obvious course was to try to improve the patient's condition by administering thyroidin. This was done repeatedly, and always reduced her weight, the first time b}' 10 kilogrammes. At the same time menstruation recurred after a cessation of two years, and returned pretty regularly from that time onwards. But no improvement in the psychical condition could be discovered on examination. Latterly, when the remedy was administered, a feeling of very great weakness set in. The patient wished to stay in bed, the pulse became very small and frequent, and oedemata were ob- served, which soon induced us to discontinue the treatment. However, the patient had appreciated the effect of it quite well herself, and often begged to be made thinner again. In children with incipient cretinism all arrest of development and signs of the disease may be removed by the administration of thyroidin, but in this case we must suppose that, with the long duration of the malady, changes have taken place which are now incurable.* Cretinism is one of the few forms of insanity in which we can obtain at any rate an approximate idea of the connection * The patient has been twelve years in the hospital unchanged. 22 — 2 340 Lectures on Clinical Psychiatry between cause and effect. We know that the disease only arises when the activity of the thyroid gland is arrested, but is certain to arise then. As the pernicious effect of this injury is obviated by the introduction of dead thyroid matter, derived from animals, the action of the thyroid gland, which comes under consideration here, can only be to afford a material absolutely necessary to the regular economy of the body. Whether this substance is directly needed for the building-up of the tissues and the carrying-on of their work, or if its use is to destroy other and injurious matter, as seems more probable, is still uncertain. In any case, we have, both in cretinism and in myxoedema, an example of the fact that the destruction of a small constituent portion of the body may bring about severe disturbances in its whole economy, and, more especially, may be the cause of insanit}-. It makes no difference in what way the destruction of the gland is effected — whether by excision, tuberculosis, syphilis, the formation of tumours, the endemic poison of cretinism, or any other injurious influence. Quite dissimilar external causes may thus produce the same picture of disease by destroying the same link in the chain of the process of metabolism of the tissues, and thus giving rise to the same morbid changes in the physical and mental economy. Our knowledge of such connections is of very recent origin. It is therefore conceivable that similar relations may some day be discovered in other forms of insanity. Perhaps we may hope more especially for some such enlightenment in general paralysis of the insane. As we have already intimated, this paralysis is far from being a simple disease of the brain. Indeed, the most different tissues of our body are involved in such a way that it is impossible to explain the disturbances simply as a condition resulting from changes in the brain. Here, too, profound and universal revolutions must take place in the physical economy, of which the immediate cause is as yet completely unknown. On the other hand, we know with absolute certainty the more subtle and remote cause of general paralysis — that is, syphilis. Yet the paralysis can hardly be a simple form in which syphilis appears, as it can perfectly well be distinguished both clinically and anatomically from syphilitic lesions of the cortex. Appar- ently, there is some intermediate link, by the agency of which the syphilitic poison produces the paralytic affection of the whole body. Far more mysterious is the origin of the enormous number of Cretinism — Concluding Remarks 341 illnesses in which, from the clinical point of view, a peculiar feeble- mindedness, and, from the anatomical standpoint, extensive disease and destruction of important constituent parts of the cortex arise without any tangible cause. The foremost place among these is held by the widely-diffused varieties of dementia prcBcox. Obvious as may be the clinical resemblance of this disease to general paralysis in many respects, it is yet improbable that it is produced by any external injurious influence. We only know that the years of physical development form a favourable soil in which the disease may break out, as is also the case in maniacal-depressive insanity. Moreover, the work of reproduction in women, and, lastly, deprivation of liberty, seem also to favour its appearance. The absence of external causes in this disease, and its relation to special radical changes in the physical economy, might perhaps suggest that here too we have an illness of which the final cause must be sought in disturbances in the metabolism of the tissues. The same may hold good of many forms of idiocy, and also, in a certain sense, of arterio-sclerotic affections of the cortex, especially in consideration of the injurious effect of the supra-renal secretion on the bloodvessels. Very wide recognition has been given to the opinion that epilepsy also is occasioned by definite poisons, produced in the body itself. Substances have even been pointed out which are supposed to play the part of causes in this disease, and methods of treatment have been based on such ideas. Our uncertainty as to the question whether, and how far, epilepsy is one single disease at all makes the clinical consideration of the subject very complicated. But if there be wide departments here in which we are obliged to proceed by quite indefinite conjectures, we do know of a little group of clinically similar affections in which we can make definite and tangible external causes responsible for the develop- ment of feeble-mindedness : I refer to feeble-mindedness after acute infectious diseases, particularly after typhus and small-pox, and also to the encephalitic forms of idiocy. Here we see how the poison of the disease, whether directly or by the agency of organic affections, occasions disturbances in the tissues of the cerebral cortex which may produce the clinical picture of in- curable dementia. We can hardly doubt that we have to deal with toxines in such cases, and these experiences suggest the con- jee ture that ordinary dementia precox may also have poisonin 342 Lectures on Clinical Psychiatry of the cerebral cortex for its immediate cause, although we are not yet in a position to discover their more remote origin. But it is only very occasionally, by comparison, that the acute infectious diseases lead to permanent dementia. As a rule, the disturbances caused by the poison of the disease disappear during convalescence. After articular rheumatism and erysipelas in particular, incurable disturbances seem absolutely never to occur, although both these diseases are rather frequent causes of in- sanity. These examples, which prove that unmistakable and severe poisoning of the cerebral cortex may gradually disappear completely, help us to understand, to a certain extent, the remissions we so often observe in both general paralysis and dementia praecox. In these affections, however, a further ad- vance of the illness almost always takes place sooner or later. This points to the fact that here, in contrast to what occurs in infectious diseases, the source of the poison is not exhausted, but may at any time show a renewed activity. We meet with just the same contrast in the effect of poisons introduced from without, in which the quickly vanishing dis- turbance caused by a few doses must be opposed to the per- manent mental failure resulting from their habitual use. It is from the investigation of this particular group of mental disturbances — alcoholism, morphinism, cocainism, etc. — that I think we may chiefly hope for the advancement of our clinical knowledge, as cause and effect are here so plainly defined that we can easily draw conclusions as to the forrrier from the latter, and vice versa. We can produce the same disturbances at any time with the utmost certainty by introducing the poison, and so can follow out in the minutest detail the invariable relation between the injurious influence and its effects, not only in clinical observa- tion, but also in psychological experiments. By such investigations we can easily discover that in poisoning, as in other iUnesses, we have to distinguish between direct and indirect effects. The morbid conditions produced by the abuse of alcohol are far more varied than we should naturally expect the effects of a single cause to be. Among them all, only in- toxication, pathological intoxication, and simple alcoholic feeble- mindedness agree with the experience afforded us by psycho- logical investigation. Other forms — i.e., delirium tremens, Kors- sakow's disease and alcoholic delirium, have entirely different features. These and other reasons lead us to suppose that what Cretinism — Concluding Remarks 343 we see is only partly due to the direct effect of the poison in these diseases, and that we have to deal with conditions resulting in the body, only indirectly brought about by long abuse of alcohol. The relation here between cause and effect is possibly similar to that between the endemic cause of the disease and the feeble-mindedness in cretinism, or to that which we assume between syphilis and general paralysis of the insane. Those forms of insanity which follow as the result of exhausting influences, and particularly of severe mental, emotional, or physical overstrain, are usually also explained as the effect of poisoning, but of poisons originating in the body itself. It is assumed that in such cases the waste products which are produced in excessive quantities cannot be eliminated from the body or rendered harmless quickly enough, and so find an oppor- tunity of exercising their baneful effect on the cerebral cortex. Although this question does not seem to me ever to have been satisfactorily answered, the possibility of such occurrences in acute and chronic nervous exhaustion can hardly be disputed. But here the expenditure by the tissue of its reserve of strength might also have some effect. Besides the effects of poison, it is only the grosser lesions of the tissue of the cortex, brought about by haemorrhage, laceration, pressure, interruption of the supply of blood, and similar injuries, that we are able to understand to any real extent at present. Perhaps we may include with these what is called concussion of the brain. The gradual change in the cerebral cortex in old age, which we have learned to recognise as the foundation of various forms of mental disturbance, is much less clear. Decisive changes may take place in the nerve tissue itself, but disturbances caused by changes in the bloodvessels, or other revolutions occurring in the body under the influence of age, may well play their part. It is certainly most probable, considering the variety of the clinical conditions presented by the mental diseases of old age, that the ways in which they arise also differ from each other on many points. The effect of the physical and mental changes of old age, apart from the results of diseases and of the hfe-history, depends to a great extent on the personal idiosyncrasy. And m the other forms of insanity also this is often a very important factor, and the more so the more superficial the injury which brings on the illness. On the one side are poisons, which, when taken in 344 Lectures on Clinical Psychiatry sufficient doses, overpower any brain, however great its power of resistance may be. At the other pole we find diseases of which the essential cause lies in the personal idiosyncrasy, and in which external influences only give an immediate impulse to the out- break of the illness, and under some circumstances may be alto- gether absent. As examples of these forms, we have maniacal- depressive insanity, paranoia, and also hysteria, to which fright neurosis is closely allied, although in this last the external cause is of much greater importance. The various forms of morbid disposition which we have seen in permanent psychopathic deterioration, in insanity with irre- pressible ideas, irresistible fears, and uncontrollable impulses, and the various forms of congenital states of disease and morbid per- sonalities, and finally in those forms of congenital feeble-minded- ness which depend on the arrest of development, are still less dependent in their origin on particular injurious influences. Here we have always to deal, not with the incidents in a definite course of disease, but with morbid states, which continue through- out the whole of life with substantially the same intensity, although sometimes with certain fluctuations. We are therefore justified in considering them to be the outcome of degeneration, which in most cases is not acquired by individuals, but is in- herited by them, and is generally handed on to succeeding generations. If you will now look back along the whole course we have traversed, you will see that mental disturbances may arise from the single or repeated introduction of such poisons as cause con- siderable injury to the cerebral cortex. Moreover, similar poisons may be produced by provocatives of disease which force their way into the body, and may also arise from the processes of tissue metabolism. The effect of these poisons may perhaps be con- nected with excessive expenditure of the reserve of strength existing in the tissues. As we suppose, a further source for the production of poisons may be found in the disorders of particular organs of the body of which the action is necessary to its economy, though certainly it is only in cretinism that this assumption is at all safe. In addition to the poisons, we must also ascribe a part in the origination of mental disturbances to the more or less complete destruction of the tissue of the cerebral cortex, and to changes brought about in it by old age. The last group of forms of insanity consists of morbid conditions, existing Cretinism — Concluding Remarks 345 from childhood, which either persist without alteration or form the basis of various disturbances running their course in a series of attacks. Such, in their essential features, are the points of view from which the clinical forms of insanity may be grouped to-day. Always starting from the relations of cause and effect, we may hope to discover clinical pictures such that the similarity or dissimilarity of the conditions under which they arise will find a clear expression in their phenomena, course, and termination. It is true that at present we are at every step met by obscurity and doubt in forming a practical judgment on the material of clinical experience. We are still so far removed from a real knowledge of the causes, phenomena, course, and termination of the individual clinical forms that we cannot yet dream of a surely established edifice of knowledge at all. What we have formulated here is only a first sketch, which the advance of our science will often have occasion to change and to enlarge in its details, and perhaps even in its principal lines. THE SERO-DIAGNOSIS OF GENERAL PARALYSIS During the last few years important investigations have been made in regard to the blood and cerebro-spinal fluid in general paralysis. The results obtained have been instrumental not only in confirming the syphilitic origin of general paralysis, but they have also afforded valuable methods for diagnosing the existence of the disease. The tests are especially useful in the earlier phases of the disease, when a correct diagnosis is some- times a matter of considerable difficulty, since the clinical signs are anomalous and liable to be confused, not infrequently, with less serious disorders, such as neurasthenia. The existence of lymphocytosis in the cerebro-spinal fluid has long been recognised as an aid to diagnosis in general par- alysis (" Lectures," p. 199)., In addition to this, it has been found that in this disease there is a considerable increase in the proteid contents of the cerebro-spinal fluid. A minute amount of proteid is normally present in the cerebro-spinal fluid, but it is much increased in inflammatory conditions of the meninges and metasyphilitic affections, such as tabes and general par- alysis, and can be recognised by much coarser tests. Thus, by Heller's test, as used in the examination of urine, a ring is formed which, by its density and thickness, can be recognised as deviating from the normal. There is a considerable difference of opinion as to the exact nature of the proteid present m the cerebro-spinal fluid of general paralysis, and the question cannot as yet be regarded as definitely settled. In all probability the proteid present in this disorder is a euglobulin, and is due to a process of leucolysis. These questions, however, are chiefly of theoretical interest, the more practical side being the demonstration of certain reactions which indicate the presence of certain substances in the cerebro-spinal fluid of general paralytics which do not occur in that of the normal individual. Two tests may be especially mentioned — viz., Nogouchi's and that devised by G. W. Ross and E. Jones. 346 The Sero-Diagnosis of General Paralysis 347 The former of these is performed as follows : To 01 c.c. of cerebro-spinal fluid is added 0-5 c.c. of a 10 per cent, solution of butyric acid in physiological saline. The mixture is heated to boiling, and then q-i c.c. of 4 per cent, sodium hydrate is added, and the mixture again heated to boiling. The test should be carried out without any pause. The reaction is positive when a peculiar light greyish floccular deposit occurs. This should come within half an hour, and usually does within a few minutes. This test is utilized for both the examination of the blood-serum and cerebro-spinal fluid, and Nogouchi considers that when it is positive in the latter a diagnosis of general paralysis is prob- able, though it may at times be present in syphilis of the nervous system. The Ross- Jones test is very simple, and consists in the addition of clear cerebro-spinal fluid to a saturated solution of ammonium sulphate, in such a manner that the fluid lies on the reagent with- out blending with it. If the reaction is positive, at the junction of the two fluids a definite, sharply defined, thin white film forms im- mediately, or almost immediately, which, when looked at against a dark background, has very much the appearance of a cobweb. The test which has excited the most interest and attention is that known as the " Wassermann reaction." It is possibly some- what more reliable than the preceding, but has the disadvantage that it can only be undertaken by a skilled bacteriologist, owing to its difficulty and the elaborate nature of its technique. The essential principle of the reaction depends on the discovery that when the blood-serum of a syphilitic patient is mixed with an extract from syphilitic material, it has the property of fixing the " complement " of normal blood-serum. To under- stand this fact some reference to the question of hsemolysis is necessary. In 1891 Bordet discovered that if the blood of one species of animal were injected into that of another, the serum of the latter developed the property of dissolving the corpuscles of the former. Thus, if the blood of a sheep is injected into that of a rabbit, the serum of the rabbit gains the power of dis- solving the corpuscles of the sheep if added to it. Now, if the haemolytic serum of the rabbit is heated in a test-tube, it is found to have lost its solvent power ; but if a little serum from a normal rabbit is added to the heated serum, the property of dissolving the sheep's corpuscles is regained. From this it appears that in haemolysis the interaction of two 34^ Lectures on Clinical Psychiatry- bodies is necessary — (i) a substance described as the complement, present in normal serum, and destroyed by heat ; (2) a substance named variously copula, amhocepior, or immune substance, more stable and resistant of heat, and only developed in immunized animals. Now, when inactivated haemolytic serum is added to the corpuscles of the homologous series (the corpuscles having been previousl}^ washed in saline solution to remove any comple- ment containing serum), such corpuscles are described as " sen- sitive," and only require the addition of normal serum to pro- duce haemolysis. Thus, supposing washed sheep's corpuscles are " sensitized " with inactivated rabbit's serum, they only require the addition of the complement — i.e., normal serum^ to become dissolved. Now, it has been found that the blood or cerebro-spinal fluid of general paralytics has the property, when combined with syphilitic material, of binding the comple- ment of normal serum, so that, when this is added to " sensi- tized " corpuscles, haemolysis no longer occurs. This constitutes theWassermann reaction. An emulsion is made of the syphilitic liver of a foetus, and added to an equal quantity of the blood- serum or cerebro-spinal fluid of the patient to be tested, together with the blood-serum of a normal guinea-pig. The mixture is incubated at ^j° C, and after a suitable interval there is added thereto " sensitized " sheep's corpuscles. If no haemolysis occur, the reaction is positiv^e — i.e., the complement in the guinea-pig's blood has been fixed and rendered inert by the blood of the patient and the syphiUtic liver emulsion. If the blood of the patient be nor- mal, the complement remains unchanged, and haemolysis occurs. The exact nature of the bod}' in the blood and cerebro-spinal fluids in general paralysis which gives rise to the phenomena of the Wassermann reaction is doubtful. It is probably not an anti- body in the usual sense of the word, but rather some form of proteid (euglobulin). That it is not a specific antibody appears to be certain from the fact that it shows the same power of inhibiting haemolysis when combined with substances other than the syphilitic virus, such as lecithin, bile salts, brain emulsion, and normal liver emulsion. This theoretical side of the question is, how- ever, of secondary importance. From the practical side the re- action is of the greatest utility in the diagnosis of general paralysis; for while a negative reaction does not altogether exclude the exist- ence of the disease, a positive reaction in the cerebro-spinal fluid, to all intents and purposes, constitutes a proof of its existence. APPENDICES APPENDIX A MELANCHOLIA AND MANIACAL-DEPRESSIVE INSANITY The conception of maniacal-depressive insanity is a wide generali- zation bringing a number of types of mental disorder, hitherto regarded as independent, into one large group. The psychoses include simple mania and melancholia, recurrent mania and melancholia, circular insanity [folie circulaire) and folie a double forme. Kraepelin observed that simple mania was always followed by a relapse at some period or another, and he did not consider that the more or less regular repetition and alter- nation of attacks of mania and melancholia were characteristics of sufficient importance to constitute a basis for separate types of mental disorder. All these forms he regarded as simply phases of one fundamental malady — maniacal-depressive insanity. While this psychosis embraced most of the various forms of depression, with the exception of those included in the dementia praecox group and general paralysis, Kraepelin separated from maniacal-depressive insanity the depression of the involutional epoch. This state of depression, characterized by an anxious affective state and ideas of sin and unworthiness, he described as melancholia, as distinct from the depressed phases of maniacal- depressive insanity. Under the category of melancholia he in- cluded " all morbid conditions of anxious depression in later life which do not represent phases of some other forms of insanity." This view has recently undergone some modification. In 1907 Dreyfus* published a monograph in which he advocated the inclusion of involutional melancholia in the maniacal- depressive group. This view was reached after a prolonged study of the Heidelberg material, and was based (i) on a more * ' Die Melancholic ein Zustandsbild des Manisch-Depressiven Ir- reseins." 349 350 Lectures on Clinical Psychiatry- complete observation of the case-histories, (2) on an analysis of the actual symptoms. As regards the first point, Dreyfus observed that many of the involutional cases which had apparently become demented and permanently enfeebled in mind subsequently completely re- covered. Furthermore, many of these cases after a time re- lapsed, following the same course, therefore, as the ordinary maniacal-depressive cases. A close inquiry into the previous history also revealed the fact that there had been in some instances earlier attacks of depression or excitement, or at least marked emotional fluctuations. As regards the second point, a further analysis of the cases showed that the characteristic symptoms of the depressed phase of maniacal-depressive insanity were in some degree to be observed in involutional melancholia. The depression of maniacal-depressive insanity is characterized by the impediment of volition, a general inhibition of intellectual and motor func- tions. Such inhibition, Dreyfus observes, is often present in some degree in the involutional cases. The patients complain of a subjective feeling of inadequacy, a loss of will-power, fatigue, a want of interest in the ordinary affairs of life, though there may be no evidence of hesitancy and retardation. The inhibition is partial rather than complete. Furthermore, many cases approximate to the " mixed " type of maniacal-depressive insanity, and reveal maniacal symptoms in association with the depression. Thus, rapid emotional changes from depression to exhilaration or excitement, maniacal outbursts of anger and irritability, distractibility of the attention, impul- sive speech, and flights of ideas, are not infrequently observed. Thus, the course of the psychosis, with an absence of mental deterioration, and the character of the symptoms are the factors which have suggested the inclusion of involutional melancholia in the maniacal-depressive group. When dementia ensues, the case is probably complicated by the existence of arterio-sclerosis. It is of interest to note that the peculiar ideas of sin and un- worthiness, as well as an anxious affective state, are also met with in early life, sometimes even in childhood. On the whole, the view advanced by Dreyfus appears to be gaining ground, and it would appear to have the assent of Kraepelin himself. The point is important, and not merely of academic interest, as it has obvious prognostic bearings. Appendices 3 5 1 APPENDIX B THE MANIACAL-DEPRESSIVE CONSTITUTION In Lecture XXVIII., under the heading of " Congenital States of Disease," reference is made to the fact that periodical states of excitement and depression are often the expression of a morbid constitutional state. The existence of a large number of indi- viduals subject to pronounced emotional fluctuations is gener- ally recognised. There is the individual who exhibits a daily cycle in this respect, a mood of gloom and pessimism in the morning giving place to a state of liveliness and exhilaration in the evening. Again, the man who at one time is recognised as " the life of the party," at another is especially liable to exhibit himself as the proverbial " wet-blanket." Such constitutional abnormalities, which bear a close relationship to maniacal- depressive insanity, have been the subject of an exhaustive analysis by Pierre Kahn. The study is of interest, since it supplies the connecting-links between normal states of mind and the abnormal manifestations of maniacal-depressive insanity. The writer contends that there exists a definite psychopathic constitution, characterized by a congenital state of instability, in which very trivial mental or physical disturbances produce striking alterations of mood, either in the direction of depression or excitement. These emotional changes may also manifest themselves apart from any obvious exciting causes. This state of unstable mental equilibrium is described as the " cyclothymic constitution," and is found usually to depend upon hereditary factors. The symptoms generally appear in adolescence, and vary greatly in degree, passing by insensible gradations from manifestations approximating to the normal to severe attacks of maniacal-depressive insanity. In the milder forms of this abnormal constitution are to be found many eccentrics and querulents. Its existence is always to be suspected when prominent emotional disturbances arise from inadequate causes, this being the practical standard by which its manifesta- tions are to be distinguished from normal reactions. The recog- nition of the cyclothymic constitution is of medico-legal im- portance, since it may manifest itself by acts of an antisocial character. Thus, the prodromata not infrequently take the 352 Lectures on Clinical Psychiatry form of malicious misrepresentation of character in respect to those associated with the patient. It must be observed that this view is not merely an extension of the boundaries of maniacal-depressive insanity to include minor emotional fluctuations, insufficient to constitute actual insanity: it accentuates the fact that both grave and mild emotional disturbances, occurring periodically, are to be re- garded as the expression of an inborn temperament. Attacks of mania and melancholia may be separated by an apparently normal phase, but the constitutional instability still exists, and can usually be demonstrated by continuous and careful observation. This aspect of maniacal-depressive insanity is one of con- siderable significance, since it affords some insight into the etiological factors of the psychosis. It demonstrates that only a particular type of individual is liable to develop this particular form of insanity, and that its manifestations are to be regarded as an exaggeration of a pre-existing disposition. In the light of these observations the necessity for an exhaustive inquiry into the previous temperament of the insane becomes apparent. Further mention is made of this aspect of insanity in connection with dementia praecox. APPENDIX C DEMENTIA PRvECOX Dementia pilecox is probably the most important conception which has been introduced into psychiatry in modem times. It has been subjected to a great deal of investigation, a complete account of which it is impossible to furnish in a brief summary. At the same time it may be useful to describe the general trend which these researches have taken, since they represent the introduction of a broader and more comprehensive view of certain types of mental disorder. The conception has met with a certain amount of criticism, largely directed towards the terminology. Other names have been suggested, such as " primary dementia " and " schizo- phrenia," the latter designation being suggested by Bleuler, owing to the existence of mental dissociation as a prominent feature of the psychosis. The nomenclature is not, however, Appendices 353 a matter of vital importance, and the original term, " dementia prsecox," is generally accepted, and has been introduced into most of the recent textbooks. The actual existence of the psychosis, which Kraepelin has outlined, can scarcely be ques- tioned. The term brings together a number of variable clinical pictures which display certain fundamental traits in common, and all tend towards progressive mental deterioration. Although, as a matter of convenience, the psychosis is divided into three main groups — hebephrenic (simple), katatonic, and paranoidal — they are not to be regarded as distinct types, since one shades imperceptibly into the other, and all are characterized by the fundamental derangements which Kraepelin has elucidated. One of the most important features of the psychosis is the peculiar character of the " dementia," which sharply differenti- ates it from the mental deterioration of general paralysis or senility. Clinical observations and more accurate pyschological investigation have tended to confirm the absence of any actual quantitative loss of function in dementia praecox, such as occurs in organic disorders. Thus, while in the latter there is a per- manent or increasing inability to retain and elaborate impres- sions— " a diffuse disorder of the activization of memories " — in dementia praecox the defect in memory is only secondary to a primary defect of attention and interest. Neither apprehension nor retention, therefore, play an important part in the deteriora- tion of dementia praecox, which is dependent on emotional and volitional factors. While, therefore, the term " dementia " can suitably be applied to the psychosis in so far as it indicates a general impair- ment of mental efficiency and disruption of judgment, it differs in essential characters from the more obviously organic disorders to which the same term is applied. The recognition of this fact is of importance, since it suggests that dementia praecox is akin to other forms of mental derangement, such as hysteria or paranoia, which also depend upon anomalies of the emotional sphere. The resemblance of dementia praecox to these other disorders indicates the lines upon which investigation may be pursued, and suggests that the psychosis is the product of similar factors. This has proved to be the case. Just as hys- teria and certain paranoic states bear a relationship to the previous mental make-up of the individual, so also may the curiously distorted personality in dementia praecox be regarded 23 354 Lectures on Clinical Psychiatry as the outgrowth and development of a particular type of morbid constitution. It is well known that individuals behave themselves towards situations, as they arise, according to their particular mental constitution or character. While some persons habitually react vigorously and decisively to situations which present themselves, others seek refuge in evasions or temporize, exhibit persecutory ideas, or indulge in fruitless worrying. While in normal people the individual constitution simply determines success or failure in life, Adolph Meyer has shown, from careful studies of the earlier histories of dementia praecox cases, that the evasive form of reaction ma}' become so habitual and extreme that the character is undermined and the soil prepared for ultimate de- terioration. This process he describes as follows : " In cases of dementia praecox we find over and over again an account of exemplary childhood, with a gradual change at the period of emancipation. Close investigation shows, however, that the exemplary child was often exemplary under a rather inadequate ideal, an example of goodness and meekness rather than of strength and determination, with a tendency to keep to the good in order to avoid contests and struggles. Later on, religious interest may become very vivid, but also largely in form rather than in reality ; disconnection of thought and un- accountable whims make their appearance, with deficient control in matters of ethics and judgment. At home irritability shows itself, often disguised as moralizing about the easygoing life of brothers and sisters, while sensitiveness to allusions to pleasures, health, etc., drive the patient into seclusion. Headaches, freaky appetite, general malaise, hypochondriacal complaints about the heart, etc., unsteadiness of occupation and inefficiency, day- dreaming, and utterly immature philosophizing, are noticed ;. and, above all, loss of directive energy and initiative without any obvious cause, such as well-founded preoccupations, except the inefficient application to reality. All these traits may be transient, but are usually not mere ' neurasthenia,' but the beginning of a deterioration, more and more marked by an indifference to emotional life and ambitions and a peculiarly fragmentary type of attention, with all the transitions to the apathetic state of dementia." Dementia praecox is thus the culmination of a 'ong-continued series of faulty mental habits. The predementia praecox char- Appendices 355 acter is one in which the individual habitually ceases to apply himself vigorously to the real facts of life. His thoughts are devoted to day-dreams and fantasies, and by constantly seeking refuge in evasions he loses the capacity for grappling with diffi- culties. Thus, in the presence of some added stress, which the ordinary individual would be prepared to meet, " the sensitive and weakened individual will react with manifestations constituting the ' deterioration process ' of dementia praecox." The constitutional factors in dementia praecox have also been the subject of investigation by August Hoch. In a large majority of cases he finds that what he describes as a " shut-in personality " existed before the onset of the psychosis. He thus delineates this type of individual : " We find m dementia praecox persons who have no natural tendency to be open and to get into contact with the environ- ment, who are reticent and seclusive and cannot adapt them- selves to situations, who are hard to mfluence and often sensitive and stubborn, but the latter "mere in a passive than an active way. They show little interest in what goes on, and frequently 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 unburden their minds, are shy, and have a tendency to live in a world of fancies. This is the ' shut-in personality.' " The writer then proceeds to show that such a constitution must present a serious menace to the balance of the personality : " This inability to get into contact with the environment brings many dangers in its train. It prevents the active and aggressive shaping of the situation which is so important for the progress of the normal individual, and spares him future conflicts ; it prevents those corrective influences which are constantly fur- nished by the actual experience gained in mingling with other people, and mutual action and reaction, and it fosters the growth of unproductive fancies. Everyone has an inclination to day- dreaming, but, apart from the fact that they play a rather subsidiary role in the normal and robust person, such fancies often represent the first dim outlines of future plans,, and there- fore are not without reference to reality, and derive their value from the possibility of their practical application. But fancies which are out of contact with reality probably exert in themselves a fascination which progressively limits objective interest. More- 23—2 356 Lectures on Clinical Psychiatry over, these very tendencies make the individual unfit to acquire the constructive plans and hopes, not necessarily elaborated, but felt and dimly appreciated, upon which the normal person lives, and which give him the very essence of his existence. There is an absence of that progressive and prospective satisfaction which cannot be too much insisted on as necessary for the retention of mental health. Active contact with the world makes, of course, more demands upon the individual than a life of 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 — lack of contact with the environment, satisfaction with fancies instead of objective interests, and want of constructive aims and aggres- siveness— must have dangers in them, which it would be difficult to exclude as dynamic factors in the development of these disorders." From these studies it appears that dementia praecox is to be regarded as the development of a particular constitutional state. The peculiar deterioration is the expression of " shut-in " traits in the extreme form of complete withdrawal of the personality from reality and absorption in dreams and fantasies. These observations do not preclude the belief that the onset and successive aggravations of dementia praecox are determined by the action of a toxin, either absorbed from without or the product of defective metabolism. The toxin would naturally have most effect in the direction of least resistance, and result in the exaggeration of original cerebral defects. Further valuable contributions to the subject of dementia praecox have been furnished by Jung, who has shown that the trends of thought in this psychosis bear a close relationship to the individual mental life, and that the apparently senseless manifestations which occur are the distorted expression of certain definite mental conflicts, determined by intimate personal circum- stances and desires. It is impossible to do more than refer to these investigations by Jung, which are of considerable impor- tance to the student of insanity. They serve to accentuate the fact that, while psychoses are suitably grouped into certain broad types of reaction, tending to pursue a particular course, in another sense each case constitutes an entity in itself, the particular contents of which are the product of purely personal factors, dependent on the individual mental history of the patient. Appendices 357 The views which have been formulated here indicate that cHnical psychiatry does not merely consist in the formal differ- entiation of a psychosis : it must include a study of the personality itself, the temperament and general reactions, and also an analysis of the aspirations, wishes, and confhcts, which have pre- ceded the outbreak of definite mental disorder, and in a great measure determine its occurrence. The psycho-biological con- ception of dementia praecox, which regards it as the terminal episode of an abnormal mental constitution, as the product of long-continued errors of adjustment, not only affords a com- prehensive view of the psychosis, but also give indications for prophylactic lines of treatment or measures by which the cul- minating disaster may be avoided. If the predementia praecox characteristics were recognised as pathological manifestations in their early stages, it would seem that much could be done by careful education and direction to overcome the morbid ten- dencies and habits which are in danger of becoming established. It will be seen from the preceding observations that stress has been laid on the mental factors bringing about this peculiar form of deterioration. It must not be forgotten, however, that the dementia is the correlate of a disturbance in cerebral function, and may be regarded from this point of view. J. Shaw Bolton groups these cases under the heading of " Primary Neuronic Dementia," including under this category " all cases in which a more or less extensive dissolution of the cortical neurones of deficient durability has occurred, either as the result of actual wearing out of these structures or in consequence of the applica- tion of one or more of the various forms of physical or mental ' stress,' or as the direct action of toxins." This primary neuronic dementia may be divided into four groups : (i) Senile or " worn-out " dementia ; (2) presenile or climacteric dementia ; (3) mature or adult dementia ; (4) premature dementia (dementia praecox). Premature dementia thus includes those cases which undergo a greater or lesser degree of neuronic dissolution, with consequent stationary dementia, between the ages of puberty and maturity. " A large proportion of these cases break down, not only under the influence of the metabolic disturbances which are associated with puberty, but also, and probably more often, under the mental ' stress ' involved in the general changes in the functions of the cerebrum from the mere acquisition of information necessary for the performance of the higher pro- 358 Lectures on Clinical Psychiatry cesses of mind — namely, the orderly aggregation and selection of facts, the co-ordination of these into suitable sequences of ideas to enable judgments to be evolved, and the turning of acquired information to practical uses, which change of cerebral function also commences about the period of puberty. Under this ' stress ' cases possessing higher cortical neurones of deficient durability go to the wall. It is thus readily intelligible that this class must include not only cases of relatively high mental capacity, whose cerebra have, by overstudy and intense applica- tion, been strained beyond their breaking-point, but also numbers of degenerates who, under the influence of ' stress ' which would without injury be sustained by normal subjects, have similarly overstrained what, in this instance, are deficiently durable cortical neurones. " The former type occurs not only in asylums, but also in the outside world. It is, for example, common knowledge that only a proportion of the brilliant students of medicine who during their course of study carry all before them attain in later life to eminence, this term being employed in a scientific rather than in a popular or pecuniary sense. In the remainder, over- strain has reduced their mental powers to a more ordinary level, and though of perhaps average mental intelligence, ' push,' and business capability, they are nevertheless, in a strict sense, examples of premature dementia. This condition is not, how- ever, limited to individuals of unusual mental power. Many examples of premature dementia occur in men in the possession of ordinary mental powers, who, by dint of exceptional persever- ance, have obtained the more coveted medical qualifications, and who afterwards exhibit not more, and often less, ability than is possessed by quite ordinary individuals. The writer is con- vinced that such cases are true examples of premature stereo- typism or premature dementia, which has developed under the influence of mental strain that could not be submitted to by those individuals without irretrievable damage to an appreciable number of their cortical neurones ; and that the phenomena re- ferred to are not, as is commonly stated, due simply to the absence of what is often described as a ' capacity for affairs ' or a practical, in contradiction to a theoretical, mind. " In the case of definite degenerates . . . some, after leaving school, pass from situation to situation, becoming duller after every change, either until no employer will keep them, or until Appendices 359 definite symptoms of insanity supervene ; others, under the influence of stronger minds, leave home for the large towns, or even for distant countries, and return some years later as prema- ture dements ; others, by morbid introspection and the (in many cases secondary) development of masturbation, acquire perverted sexual and hypochondriacal ideas, which undermine their powers of application, and result in their isolation in asylums. In other cases the resistance of the cortical neurones is exceeded by in- temperance in the use of alcohol and tobacco, and, in the case of girls, by the 'stress' involved in the physiological experiment of pregnancy aud subsequent maternity. Any variety of physical or mental ' stress ' may, in fact, act as the last straw or precipi- tating agent in determining the onset of an attack of insanity, and the question of whether or not enough dementia supervenes for the permanent detention of the patient depends entirely on whether a sufficiency of cortical neurones have, or have not, undergone irretrievable damage." These observations, based upon extensive clinical and patho- logical data, indicate, more from the view of cerebral function, the abnormal conditions producing that form of mental de- terioration known as dementia praecox. They afford a complete perspective of this deterioration, which is to be regarded as the premature dissolution of an imperfectly endowed psychophysical organization, or of a normal one which has been overworked. REFERENCES. 1. Adolph Meyer : An. Attempt at Analysis of Neurotic Constitution. American Journal of Psychology, vol. xiv. Fundamental Conceptions of Dementia Praecox. British Medical Journal, September 29, 1906. What do Histories of Cases of Insanity teach us concerning Pre- ventive Mental Hygiene during the Years of School Life ? Psychological Clinic, vol. ii., No. 4. The Dynamic Interpretation of Dementia Praecox. American Jourr^al of Psychology, July, 1910. 2. August Hoch : A Study of the Mental Make-up in the Functional Psychoses. Journal of Nervous and Mental Diseases, April, 1909. Constitutional Factors in the Dementia Praecox Group. Review of Neurology and Psychiatry, August, 1910. On some Mental Mechanisms in Dementia Praecox. Journal of Abnormal Psychology, vol. xv. 360 Lectures on Clinical Psychiatry 3. Jung: The Psychology of Dementia Praecox. Translatedby A. A. Brill, 1909. 4. S. E. Jelliffe : Predementia Praecox : the Hereditary and Constitu- tional Feature of the Dementia Prascox Make-up. Journal of Nervous and Mental Diseases, January, 191 1. 5. Macfie Campbell : A Modern Conception of Dementia Praecox. Re- view of Neurology and Psychiatry, October, 1909. 6. J. S. Bolton : Amentia and Dementia. Journal of Mental Science, July, 1907. INDEX Abnormalities, Constitutional, iu Relation to Maniacal-depressive In- sanity, 351 Absurd Behaviour, 32 Accidents, Psychoses in. See Neurosis, Traumatic Acute Diseases as Causes of Insanity, no Alcohol as a Cause of Insanity, 2, 99, 174 in Epilepsy, 50, 52-54, 247 in Hysteria, 256-258 in Polyneuritic Mental Disturbances, 173 Resistance of Cortical Neurones exceeded by Intemperance m, 359 Alcoholic Delirium, loi ,, Delusions, 108 ,, Poisoning, Acute, 174 Alcoholism, Chronic, 174 Treatment of, 176 Amentia, 119, 137 Aphasia, 215 ,, in General Paralysis, 202 Apoplexy as a Cause of Insanity, 215 Apprehension, Irresistible, 272 „ in Melancholia, 5 ,, of Bridges, Clothes, Dirt, Squares, 272 Arrested Development, 332 Arteries, Syphilitic Disease of, 227 Arterio-sclerosis in Involutional Melancholia, 350 Articular Rheumatism as a Cause of Insanity, 118 Attacks, Epileptic, 50, 51 Hysterical, 249, 254, 257, 301 „ in Brain Syphilis, 225 „ in General Paralysis, 200 in Idiocy, 332 „ in Katatonia, 135, 211 ,, iu Maniacal-depressive Insanity, 13 Automatic Obedience, 25 Bewilderment, Acute, 157 ^ Bloodvessels, Lesions of, in Arterio-Sclerosis, 222 „ ,, Brain Syphilis, 227 ,, ,, Senile Dementia, 231 Bordet's Discovery, 347 Brain, Coarse Lesions of, as a Cause of Insanity, 215 Concussion of, as a Cause of Insanity, 261, 343 Brain-power, Progressive Failure of. See Paralysis, General, of the Insane Bridges, Apprehension of, 272 Bromides in Mania, 67 Bromo-opium Treatment in Epilepsy, 58 Business Delirium in Delirium Tremens, 103 in Mania, 64 Catalepsy, 25 Causes of Insanity, 140, 340 Cerebral Changes in Old Age, 228, 343 361 362 Lectures on Clinical Psychiatry Cerebro-spinal Fluid, Lymphocj^osis in Proteid Contents of, 346 Character, Alteration of, after Injuries to the Head, 264 in Katatonia, 85 Hysterical, 253 the Predementia Prascox, 354, 357 Choreic Insanity, 138 Circular Insanity (see also Maniacal-depressive Insanity), 17 Depressed Stages of, 11 Classes, Auxiliary, for the Feeble-minded, 329 Clothes, Apprehension of, 272 Clumsiness of Epileptics, 240, 245 Cocainism, 183 Cognition, Impediment of, 15 Collapse, Delirium of, 137 Confusion, Hallucinatory, 119 Congenital States of Disease, 280 Constitution, the " Cyclothymic," 351 ,, in Eccentrics and Querulents, 351 from Medico-legal Point, 351 the Maniacal-depressive, 351 Constitutional Abnormalities, 351 Instability, 352 Coprolalia, 81 Cortical Neurones, Deficiently durable, 358 Resistance of, exceeded by Intemperance .n Alcohol or Tobacco, 359 Cretinism, Endemic, 338 Criminals, by Impulse, 314 ,, Habitual, 310 „ Morbid, 310 ,, Natural, 320 Professional, 310 Cytoscopy, 199 Decision, Inability to come to a, in Maniacal-depressive Insanity, 19, 75 Degenerates. 358 Degeneration, 280 sig;ns of, 240 Delirium, Cocainistic, 190 during Morphia Cure, 188 Epileptic, 127, 128 in General Paraly-tics, 121-123 ,', Katatonic, 123-125 Traumatic, 260, 243 Tremens, 100, loi, 257 Delusions in Dementia Praecox, 153 in General Paralysis, 164 in Maniacal-depressive Insanity, 76 ,, in Melancholia, 7 ,, in Paranoia, 145 of Reference to the Patient's own Person, 74 " Systematized, in Paranoia, 151 Dementia, Acute, curable, 116, 133, 341 after Injuries to Head, 261 ", Apathetic State of, in Dementia Praecox, 354 „ Apoplectic, 21S Katatonic, 38, 207 Mature or Adult, 357 Paral>'tic. See General Paralysis „ Paranoides, 158 Praecox. 21, 81, 352-359 Index ^63 Dementia Prcecox, Apathetic State of Dementia in, 354 Deficient Control in Matters of Ethics and Judg- ment in, 354 „ ,, Delusions in, 153 „ ,, Deterioration Process of, 355 „ ,, determined by Action of Toxin, 356 ,, „ Disconnection of Thought in, 354 „ „ Distorted Personality in, 353 „ ,, Final Stages of, 204 „ ,, Hebephrenic, 353 >> ,, Hysteria and Paranoia in Connection with, 353 ,, ,, Interest in Religion in, 354 ,, ,, Irritab-Iity in, 354 . ,, ,, Katatonic, 353 ,, ,, Paranoidal, 353 ,, ,, Progressive Mental Deterioration in, 353 ,, ,, Psycho-biological Conception of, 357 „ ,, Psychological Investigation into, 353 ,, ,, Remissions, 29 „ ,, " Shut-in " Personality in, 355, 356 ,, ,, Termination of, 29, 204 Terminology of, 352 „ Premature (Dementia Praecox), 357 „ ,, I3rilliant Students Examples of, 358 ,, ,, in Men of Ordinary Powers, 358 ,, Presenile or Climacteric, 357 , Primary Neuronic, 357 ,, Senile or " Worn-out, ' 357 ,, Syphilitic, 227 Depression, 49 „ Apprehensive, in Melancholia, 6, 7 „ Constitutional, 293 ,, Epileptic, 49 ,, in Maniacal-depressive Insanity, 11 „ Periodical, 294 „ Senile States of, 228 ,, States of, at the Beginning of Dementia Praecox, 25 ,, in General Paralysis, 39, 44 Derangement, 147 Deterioration Process of Dementia Praecox, 355 Development, Arrested, 332 of Masturbation, 359 Dipsomania, 181 Dirt, Apprehension of, 272 Diseases, Acute, as Causes of Insanity, no Disposition, Personal, as a Cause of Insanity', 343 Dissimulation in Hysteria, 252 ,, in Traumatic Neurosis, 267 Distorted Personality in Dementia Praecox, 354 Divertibility, 63 Drunkenness. See Alcoholism, Chronic ,, Periodical, 181 Dulness, Emotional, in Dementia Praecox, 22 in Idiocy, 335 Dwarfish Growth in Cretinism, 338 Eccentrics in Connection with the Maniacal-depressive Constitution, 351 Echolalia, 27 Echopraxis, 27 Emotional Dulness in Criminal Natures, 320 ,, in Dementia Praecox, 22 364 Lectures on Clinical Psychiatry Emotional Dulness in Idiocy, 335 ,, Fluctuations in the Maniacal-depressive Constitution, 350 Epileptic Attacks, 51 ,, Delirium, 57, 128 „ Equivalents, 55 ,, Feeble-mindedness, 238 Insanity, 49 Causes of, 341 Irritability, 57 States of Semi-consciousness, 51 Equivalents, Epileptic, 55 Erysipelas as a Cause of Insanity, 114 Euglobulin, 346, 348 Excitement, Periodical, in Katatonia, 214 Exhaustion as a Cause of Insanity, 136, 343 Fainting Fits, Epileptic, 51 Fears, Irresistible, 270, 272 Feeble-mindedness, Congenital, 328 Epileptic, 238 Fetishism, 284 Fever Delirium, 113 Final Stages of Dementia Praecox, 204 ,, ,, of General Paralysis, 193 of Uncured Mental Derangement, 217 Flexibilitas Cerea, 25 Flexibility, Waxen, 25 Folic a Double-forme, 349 ,, Circulaire, 349 Fright Neurosis, 269 General Paralysis of the Insane, 39, 89, 122, 164, 193, 340 ,, Agitated Form, 98 Ascending Form, 165 Attacks (Paralytic), 200 Blood and Cerebro-spinal Fluid in, 346 Classical Form, 92 ,, Deliriums, 121 ,, Demented Form, 195 ,, Dementia in, 194 ,, Depression, 39 Diagnosis, 44 ,, Excitement, 96 Final Stages, 193 Galloping Form, 98 ,, Grandeur, Delusions of, 90 in Women, 200 Megalomania in, 89 Pathology of Cortex, 203 Sero-diagnosis of, 346, 347, 348 ,, Terminations, 41 Treatment, 44 Grandeur, Delusions of, in General Paralysis, 90 Grimacing, 24 Habitual Criminals, 310 Hagmolvsis, 346 Hallucinations of Grandeur in General Paralysis, 89 Head, Injuries to the, as a Cause of Epilepsy, 52, 247 of Insanity, 259, 343 Hearing, Hallucinations of, in Alcoholic Delirmm, 107 Index 365 Hearing, Hallucinations of, in Arterio-Sclerosis, 222 Brain Syphilis, 227 Dementia Praecox, 27, 87, 154, 158, 159 Heller's Test, 346 Hypnotism in Hysteria, 255 „ in the Insanity of Irresistible Fears, 272 „ in Traumatic Hysteria, 258 ,, ,, Neurosis, 268 Hypochondriacal Ideas, 359 Hypomania, 61 Hysteria in Children, 254 in Connection with Dementia Praecox, 354 in Males, 255 ,, Traumatic, 258, 275 Hysterical Insanity, 249 Ideas, Flight of, 64, 350 ,, Hypochondriacal, 359 ,, Irrepressible, 270, 272 Idiocy, 326, 352 Idiosyncrasies, Personal, as a Cause of Insanity, 343 Idiots, Asylums for, 329 Illness, Patient's Sense of, 7 Imbecility, 275, 326, 329 ,, Epileptic, 238 Impulse, Criminals by, 314 Impulses, Uncontrollable, 274 Impulsive Actions in Katatonia, 81 Income, Struggle for an, 267 Infectious Diseases as a Cause of Insanity, no, 341 ,, States of Weakness, 116 Inferiority, Permanent Psychopathic, 270 Initial Delirium in Typhus, 113 Insane, General View of the, 2 ,, Numbers of the, 2 Insanity after Acute Diseases, no after Injuries to the Head, 259, 343 Alcoholic, 99, 174 ,, Causes of, 2, 340 ,, Choreic, 138 during Pregnancy, 131 ,, Epileptic, 49, 238 ,, Hysterical, 249 ,, Maniacal-depressive, 11, 349, 350 Distinction between, and Melancholia, 349 Mixed Type of, 350 Moral, 320 Polyneuritic, 171, 173, 342 ,, Prevention of, 3 ,, Puerperal, 131 Intoxication, Morbid States of, 57 Psychical Picture of, 174 Introspection, Morbid, 359 Irritability in Dementia Praecox, 354 Jealousy, Delusions of, in Alcoholics, 177 ,, Senile Delusions of, 169 Katatonia, 32 „ Attacks in, 135, 211 „ Delirium in, 125 366 Lectures on Clinical Psychiatry Katatonia, Excitement in, 79 ,, Senile Forms of, 236 Stupor in, 30 Volition, Disturbances of, 34 Kleptomania,, 314 Korssakow's Disease, 171 Laughing in Dementia Prsecox, 24 Leucolysis, 346 Lies, Morbid, 302 Lumbar Puncture, 199 Lymphoc>i;osis in Proteid Contents of Cerebro-spinal Fluid, 346 Malicious Misrepresentation associated with the Maniacal-depressive Constitution, 352 Mania, 59, 61 ,, Chronic, 291 ,, Periodical, 67 Maniacal-depressive Constitution, the, 351 Etiological Factors in the, 352 in Connection with Dementia Prae- tt »» #» cox, 352 ,, ,, Instability in the, 352 [[ „ „ Normal States of Mind in Connection with the, 351 Insanity, 11, 75, 278, 349, 350 ,, ,, Emotional Fluctuations in, 350 " ,, ,, Excited Stages in, 59 ][ ,, ,, Mixed Conditions of, 69 1. „ ., Mixed Tj-pe of, 350 States of Depression, in, 11 ,, ,, ,. Weight of body in, 14 Mannerisms in Katatonia, 81 Masochism, 284 Masturbation, Development of, 359 Melancholia, 6, 349. 35° cLS distinct from Maniacal-depressive Insanity, 349 Causes of, 9 Delusions in, 7 Involutional, 349, 350 with Arterio-sclerosis, 350 Simplex, 9 ,, Terminations of, 9 ,, Treatment of, 9 Memory, Disturbance of, in Polyneuritic Mental Derangement, 169 Disturbances of, in Korssakow's Disease, 171 Falsification of, after Injuries to the Head, 260 I, ,, ,, in Paranoia, 146 ,, ,, in Presbyophrenia, 234 ', Loss of, after Injuries to the Head, 260 Mental Diseases. See Insanity Therapeutics, Object of, i Practical Importance of, 2 ', ,, Subject of, I Mercurial Inunction in General Paralysis, 44 Treatment in General Paralysis, 166 Metabolic Disturbances associated with Puberty, 357 Metallo-therapeutics in Hysteria, 252 Metasyphilis, 44 Metas>'philitic Affections, 346 Mixed Conditions of Maniacal-depressive Insanity, i r Index 367 Mood, Alterations of, 351 ,, Fluctuations of, 65 Moral Insanity, 320 Morbid Introspection, 359 Morphine Craving, 185 Morphinism, 183 ,, Treatment of, 185 Mutism, 31 Myxoedema and Cretinism, 338 Negativism, 31 Neurosis, Traumatic, 265, 267 Nogouchi's Test, 346, 347 Normal States of ]\'Iind in Connection with Maniacal-depressive Insanity, 351 Onanism as a Cause of Disease, 24 Paralysis, General. See General Paralysis Atypical, 203 Circular, 95 Stationary, 199 Paranoia, 142 „ in Connection with Dementia Praecox, 353 Periodic, 78 Perplexity, 117 Persecution, Senile Delusion of, 166, 168 Personalities, Morbid, 295 Personality, Distorted, in Dementia Praecox, 353 Petit Mai, 57 Poisoning as a Cause of Insanity, 342 Polyneuritic (Neuritic) Mental Disturbances, 169, 342 Predementia Praecox Character, the, 354, 357 Pregnancy, Insanity of, 131 Premature Dementia, Brilliant Scholars Examples of, 358 ,, „ in jNIen of Ordinary Powers, 358 Stereotypism, 359 Presbyophrenia, 234 Professional Criminals, 310 Pseudo-querulous Cases, 309 Psychiatry. See JNIental Therapeutics Puerperal Insanity, 131 Mania, 131 Puerperium as a Cause of Katatonia, 38 Querulents and Eccentrics in Connection with the Maniacal-depressive Constitution, 351 Querulous Delusions, 152 Remissions, 342 ,, in General Paralj^sis, 95 in Katatonia, 85, 208 Rigidity in General Paralysis, 122 Insanity of (Katatonia), 32 Ross-Jones Test, 347 Sadism, 284 Saline Transfusions in Asthenic Conditions, 113, 123, 137, 201 Self-control, Morbid Want of, 299 Semi-consciousness, Epileptic States of, 51, 244 ,, Hysterical States of, 250 368 Lectures on Clinical Psychiatry Senile Dementia, 228 ,, Katatonia, 235, 236 Sero-diagnosis of General Paralysis, 346 Sexual Instinct, Inverted, 284 ,, ,, Morbid Direction of, 284 " Shut-in " Personality, the, in Dementia Praecox, 355 Simulation. See Dissimulation Sin and Unworthiness, Delusion of, 349, 350 ,, Delusion of, 5 Sleeping Attacks in Hysteria, 249 Slobbering in Katatonii, 36 Snout-cramp, 37 Speech, Confusion of, 80 Disturbance of, in General Paralysis, 43, 90, 94 ,, in Idiots, 330 Slurring, n General Pa'alysis, 94 Squares, Apprehension of, 272 Stereotj'pism, 31 „ Premature, 358 " Stress " about Period of Puberty, 358 ,, in Pregnancy and Confinement, 359 ,, involved in Changes in Cerebrum, 357 Physical or Mental, in Primary Neuronic Dementia, 357, 359 Stupor, Circular, 17 ,, Katatonic, 30 ,, Maniacal, 69 Paralytic, 95 Suicidal Tendencies in Maniacal-depressive Insanity, 19 ,, ,, in Melanchol a, 6 Swindler, Morbid, 302 Syllable-stumbling in General Paralysis, 90 Syphilis as a Cause of Insanity, 2 ,, in General Paralysis, 41, 44, 340 Syphilitic Lesions of the Cortex, 222 Origin of General Paralysis, 346 Tabic Palsy, 165 Teeth, Grinding of, in General Paralysis, 202 Thvroid Treatment of Cretinism, 339 Tobacco, Resistance of Cortical Neurones exceeded by Intemperance in, 359 Toxins in Dementia Praecox, 356 in Primary Neuronic Dementia, 357 Trauma. See Head, Injuries to the T>-phus as a Cause of Insanity, 52, 113 Vagabonds, Morbid, 320 Volition, Impediment of, 12 ,. ,, in Maniacal-depressive Insanity, 350 Wassermann Reaction, the, 347, 348 Weakness, Infectious States of, 116 ,, Secondary, States of, 204 Weiglit of Body in General Paralysis, 198 in Maniacal-depressive Insanity, 14 Word-deafness, 217 Words, Play on, 23, 24, 27 Writing, Disturbance of, in General Paralysis, 43 Bailliere, Tindail and Cox, 8, Henrietta Street, Covent Garden I Or O